Medical Provider Network ( MPN) Employee Notice To All Employees: Your employer is committed to your well-being and safety at the workplace. Keeping injuries from happening is our first concern. However, if you do have a work injury, it is our goal to help you recover and return to useful employment as soon as it is medically possible. Your employer is utilizing the OneBeacon-Coventry CA MPN as their network of medical providers. The MPN is a Worker’s Compensation Provider Network built around Occupational Care Providers. The MPN will be delivered through Coventry’s network of medical providers and facilities. Coventry is a nationally recognized company which specializes in occupational health, disability management and medical cost management. The MPN includes occupational health clinics and doctors who will provide you with medical treatment. The occupational doctor will also manage your return-to-work with your employer. Under the MPN program, you will be provided: − − − − a primary treating physician; other occupational health services and specialists; emergency health care services; and medical care if you are working or traveling outside of the geographic services area. This network has been built to provide you with timely and quality medical care. The MPN is easy to access and is here to provide you with quality medical care, and to assist you to return to health and a productive life. MPN Implementation Notice Dear Employee: Unless you predesignate a physician or medical group, your new work injuries arising on or after _______________ ( insert effective date of new MPN) will be treated by providers in a new Medical Provider Network, OneBeacon- Coventry CA MPN. If you have an existing injury, you may be required to change to a provider in the new MPN. Check with your claims adjuster. You may obtain more information about the MPN from the workers’ compensation poster or from your employer. PRINT CLEAR PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment, you may be treated for such injury or illness by your personal medical doctor (M.D.), doctor of osteopathic medicine (D.O.) or medical group if: • • • • • on the date of your work injury you have health care coverage for injuries or illnesses that are not work related; the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records; your “personal physician” may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group providing comprehensive medical services predominantly for nonoccupational illnesses and injuries; prior to the injury your doctor agrees to treat you for work injuries or illnesses; prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor's name and business address. You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met. NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee: Complete this section. To: ____________________________ (name of employer) If I have a work-related injury or illness, I choose to be treated by: _________________________________________________________________ (name of doctor)(M.D., D.O., or medical group) _________________________________________________________________ (street address, city, state, ZIP) __________________________________________________ (telephone number) Employee Name (please print): _____________________________________________________________________________________________ Employee's Address: _____________________________________________________________________________________________ Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses: Employee's Signature ________________________________Date: __________ Physician: I agree to this Predesignation: Signature: _____________________________________________Date: __________ (Physician or Designated Employee of the Physician or Medical Group) The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician's agreement to be predesignated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). Title 8, California Code of Regulations, section 9783. DWC FORM 9783 (7/2014) Notificación de Implementación de Red de Proveedores Médicos MPN (por sus siglas en inglés) Estimado empleado: A no ser que usted designe a un doctor o a un grupo médico específico, cualquier futura lesión que ocurra en la siguiente fecha o después de la misma ______________________ (escribir fecha de entrada en vigor de la nueva MPN) será tratada por un nuevo proveedor bajo una nueva Red de Proveedores Médicos OneBeacon – Coventry CA MPN. Si usted sufre de una lesión existente es posible que se le requiera cambiar de proveedor dentro de la nueva Red de Proveedores Médicos. Favor de verificar con su perito o ajustador. Usted puede encontrar más información sobre la Red de Proveedores Médicos en el cartel de Ley de Compensación Laboral al Trabajador o de su patrón. PRINT CLEAR DESIGNACIÓN PREVIA DE MÉDICO PERSONAL En caso de que usted sufra una lesión o enfermedad relacionada a su empleo, usted puede recibir tratamiento médico por esa lesión o enfermedad de su médico personal (M.D.), médico osteópata (D.O.) o grupo médico si: • En la fecha de su lesión laboral usted tiene cobertura de atención médica para lesiones o enfermedades no laborales; • el médico es su médico regular, que será o un médico que ha limitado su práctica médica a medicina general o un internista certificado o elegible para serlo, pediatra, gineco-obstetra, o médico de medicina familiar y que previamente ha estado a cargo de su tratamiento médico y tiene su expediente médico; • su "médico personal" puede ser un grupo médico si es una corporación o sociedad o asociación compuesta de doctores certificados en medicina u osteopatía, que opera un grupo médico multidisciplinario integrado que predominantemente proporciona amplios servicios médicos para lesiones y enfermedades no laborales; • antes de la lesión su médico está de acuerdo a proporcionarle tratamiento médico para su lesión o enfermedad de trabajo; • antes de la lesión usted le proporcionó a su empleador por escrito lo siguiente: (1) notificación de que quiere que su médico personal lo trate para una lesión o enfermedad laboral y (2) el nombre y dirección comercial de su médico personal. Puede usar este formulario para notificarle a su empleador si usted desea que su médico personal o médico osteópata lo trate para una lesión o enfermedad de trabajo y que los requisitos mencionados arriba se cumplan. AVISO DE DESIGNACIÓN PREVIA DE MÉDICOPERSONAL Empleado: Rellene esta sección. A: recibir tratamiento médico de: (nombre del empleador) Si sufro una lesión o enfermedad laboral, yo elijo (nombre del médico)(M.D., D.O., o grupo médico) (dirección, ciudad, estado, código postal) (número de teléfono) Nombre del Empleado (en letras de molde, por favor): Dirección del Empleado: Nombre de Compañía de Seguros, Plan o Fondo proporcionando cobertura médica para lesiones o enfermedades no laborales: _______________________________________________________________________________ Firma del Empleado Fecha: Médico: Estoy de acuerdo con esta Designación Previa: Firma: (Médico o Empleado designado por el Médico o Grupo Médico) Fecha: El médico no está obligado a firmar este formulario, sin embargo, si el médico o empleado designado por el médico o grupo médico no firma, será necesario presentar documentación sobre el consentimiento del médico a ser designado previamente de acuerdo al Código de Reglamentos de California, Título 8, sección 9780.1(a) (3). Título 8, Código de Reglamentos de California, sección 9783. FORMULARIO 9783 DE LA DWC (7/2014)
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