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Workers compensation Employee Notification

The Pennsylvania Workers’ compensation Act is designed to provide reimbursement for reasonable medical care for someone who suffers an injury arising in the course of his/her employment and causally related thereto.  Pursuant to the Act, your employer will provide payment for reasonable surgical and medical services, services rendered by physicians or other health care providers, medicines and supplies, as and when needed.

If you require emergency medical treatment, you may seek it from any provider; however, any subsequent non-emergency treatment shall be obtained from one of the designated health care providers whose names appear on the list posed on your employer’s premises. If you are faced with a medical emergency, you may secure assistance from a hospital or physician/health care provider of your choice. However, once the emergency no longer exists, the injured employee must treat with a listed provider for the remainder of the ninety (90) day period.

During the initial ninety (90) days from the date of your first visit, you have the right to switch from one health care provider on the list to another, and your employer will pay for that treatment.

If a designated health care provider refers you for treatment to another health care provider whose name is not on the list, your employer will pay for the treatment rendered by the provider to whom you were referred.

Naturally, you have the right to seek treatment or medical consultation form a non-designated health care provider during the initial ninety (90) day period following the first visit, but you are personally responsible for payment for those services.

You have the right to seek treatment from any health care provider at the expiration of the ninety (90) day period from the date of the first visit. Your employer will pay for this treatment unless the treatment is found to be unreasonable or unnecessary by a utilization review organization pursuant to the utilization review process contained in the Workers’ Compensation Act.

Your employer will be responsible for the cost of that treatment after the initial ninety (90) day period has ended buy only if you notify the employer that you are receiving treatment from non-designated health care provider and only if that notice is provided to your employer within five (5) days of the first visit to that provider.  If you provide notice to your employer of treatment by a non-designated provider more than five (5) days after the first visit to theta provider, the employer will not be responsible to pay for treatment rendered by that non-designated provider until it receives notification from you that you are receiving such treatment.

Should a designated health care provider prescribe invasive surgery, your employer will pay for an additional opinion from a health care provider of your choice.  If the additional opinion differs from the opinion of the designated health care provider and if the additional opinion provides a specific and detailed course of treatment, you will then determine which course of treatment to follow. If you choose to follow the procedures recommended in the additional opinion, your employer will pay to have such procedures performed by one of its designated health care providers and will not be responsible for payment for treatment provided by a non-designated provider for a period of ninety (90) days from the date of your visit to the health care provider from whom you obtained the additional opinion.

I HEREBY ACKNOWLEDGE THAT I HAVE BEEN INFORMED OF AND UNDERSTAND MY RIGHTS AND DUTIES UNDER THE PENNSYLVANIA WORKERS’ COMPENSATION ACT AS SET FORTH HEREIN.

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First Employee's Name

First Name*

Middle Name

Last Name*
First Employee's Date of Birth*
I certify that I am 15 years of age or older
First Employee's Signature*
Second Employee's Name

First Name*

Middle Name

Last Name*
Second Employee's Date of Birth*
Third Employee's Name

First Name*

Middle Name

Last Name*
Third Employee's Date of Birth*
Fourth Employee's Name

First Name*

Middle Name

Last Name*
Fourth Employee's Date of Birth*
Fifth Employee's Name

First Name*

Middle Name

Last Name*
Fifth Employee's Date of Birth*
Sixth Employee's Name

First Name*

Middle Name

Last Name*
Sixth Employee's Date of Birth*
Seventh Employee's Name

First Name*

Middle Name

Last Name*
Seventh Employee's Date of Birth*
Eighth Employee's Name

First Name*

Middle Name

Last Name*
Eighth Employee's Date of Birth*
Ninth Employee's Name

First Name*

Middle Name

Last Name*
Ninth Employee's Date of Birth*
Tenth Employee's Name

First Name*

Middle Name

Last Name*
Tenth Employee's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
EMPLOYEE RE-NOTIFICATION AT OR NEAR THE TIME OF THE CLAIMED WORK INJURY

I hereby acknowledge that I have been informed again and that I understand my rights and duties under the Pennsylvania Workers' Compensation Act.  I have received a copy of this workers' compensation employee notification form.

Employee Name: _______________________________________________________

Employee Signature:_____________________________________________________

Date: _______________

Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
I certify that I am 15 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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