Workers Compensation Acknowledgement Notice Of Rights And Duties <strong>NOTICE OF RIGHTS AND DUTIES</strong> Pennsylvania law requires employers to notify employees of their rights and duties regarding medical services provided under the Workers' Compensation Law (the Act). This notice will provide you a summary of the applicable provisions of the Act. The employer must provide payment in accordance with the Workers' Compensation Act for reasonable surgical and medical services, services rendered by physicians or other health care providers, medicines, and supplies, as and when needed. In addition, the employer shall provide payment for hospital treatment, orthopedic appliances, and prostheses in accordance with the Act. Your employer has established a medical panel, which includes at least six designated health care providers, no more than two of who are coordinated care organization and no fewer than three of whom are physicians. The employer has not included on this list a physician or health care provider who is employed, owned, or controlled by the employer or the employer's insurer unless employment, ownership or control is disclosed on the list. If you suffer a workplace injury, you are required to visit one of the physicians or other health care providers so designated and must continue to visit the same or another designated physician or health care provider for a period of ninety (90) days from the date of the first visit. If you wish to change physicians during this ninety (90) day period, you must review your employer's panel and select a new physician from the panel. If you do not comply with the above, your employer may not have to pay for the medical service rendered during such applicable period. Subsequent treatment, after the ninety (90) day period, may be provided by any health care provider of your choice. However, if you are then provided treatment from a non-designated health care provider, you must notify your employer within five (51 days of the first visit to that health care provider. Failure to so notify your employer may relieve your employer from liability for the payment for the services rendered prior to appropriate notice. In the event a posted panel physician recommends invasive surgery, you may seek a second opinion with a physician of your choice. If you choose to undergo the invasive surgery, you must use a posted physician for treatment. Your employer will ask that you sign the acknowledgement below which verifies that you have been informed and understand these rights and duties and will provide a copy to you. <strong>ACKNOWLEDGEMENT OF RIGHTS AND DUTIES</strong> I hereby acknowledge that the employer has provided me with a copy of “Notice Regarding Work- Related Injuries”. I have been informed of and I understand my rights and duties pertaining to medical treatment for work related injuries thereunder. <p><b><i>New </i></b><b><i>Hire</i></b><b><i>/initial Signing:</i></b></p> Name Name First First Last Last Signature Clear Date <p><b><i>After </i></b><b><i>Injury:</i></b></p> Name Name First First Last Last Signature Clear Date Submit If you are human, leave this field blank.
