WORKERS’ COMPENSATION EMPLOYEE NOTIFICATION
(scroll to the bottom for the Work Related Incident Report Form)
Workers’ Compensation is designed to provide wage loss benefits and reimbursement for reasonable medical care for one who is injured on the job. Your employer shall provide payment for reasonable surgical and medical services, services rendered by physicians or other health care providers, medicines and supplies, as and when needed.
Your employer, in compliance with the Workers’ Compensation Act, has posted a list of at least six (6) medical providers from which you are to select. You are to obtain treatment from one of the providers of your choice for ninety (90) days from the date of your first visit.
If you are faced with an immediate medical emergency, you may secure assistance from the closest hospital, physician or other health care provider of your choice. If follow up treatment is needed, you must then seek treatment from a physician or other health care provider listed on your employer’s physician panel list for the first ninety (90) days from the date of your first treatment.
If during the initial 90-day period you wish to change medical providers, you must once again re-visit your employer’s panel and select a new physician. If you do not seek treatment from a provider on the panel list for the initial 90 days following your first visit, your employer will not have to pay for the services rendered.
If one of the listed providers recommends invasive surgery, you are entitled to a second opinion from a physician of your choice. Should your physician’s opinion differ, and you choose that opinion, the panel physician will abide by same for 90 days.
After the initial 90-day period, if additional or continued treatment is needed, you may now choose to go to another physician or health care provider of your choice. Should you decide to change providers, you must notify your employer within five (5) days of your first visit with your new provider. Failure to notify your employer will relieve your employer of the responsibility for the payment of the services rendered if such services are determined to have been unreasonable or unnecessary.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Workers’ Compensation Information
(1) The workers’ compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury.
(2) Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers’ compensation benefits at its primary place of business and at its sties of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid.
(3) You should report immediately any injury or work-related illness to your employer.
(4) Your benefits could be delayed or denied if you do not notify your employer immediately.
(5) If your claim is denied by your employer, you have the right to request a hearing before a workers’ compensation judge.
(6) The Bureau of Workers’ Compensation cannot provide legal advice. However, you may contact the Bureau of Workers’ Compensation for additional general information at:
Bureau of Workers’ Compensation
1171 South Cameron Street, Room 103
Harrisburg, Pennsylvania 17104-2501
Telephone number within Pennsylvania (800) 482-2383
Telephone number outside of this Commonwealth (717) 772-4447
TTY (800) 362-4228 (for hearing and speech impaired only)
www.state.pa.us - PA Keyword: workers comp.
This form is to be used to report any work-related accidents by employees. It is the employee's responsibility to complete the form and return a copy to Human Resources within 24 hours of the accident. The original is to be forwarded to the employee's supervisor for the accident investigation.
In order to ensure that your medical treatment for a work-related injury will be paid by your employer or the insurance company, you must immediately advise your supervisor of your injury, and be treated by one of the licensed physicians or practitioners of the healing arts listed on this flyer.