Office of Human Resources and Risk Management

Workers' Compensation

Workers' Compensation Panel of Physicians

1. In accordance with the PA Workers' Compensation Act, your employer shall provide payment for reasonable medical services or other services rendered by health care providers when such care is directly attributable to a compensable work-related injury.

2. If your employer has established and posted a panel of medical providers, the panel must include no less than six designated health care providers, no more than four of whom may be coordinated care organizations and no fewer than three of whom shall be physicians. The employer cannot include on this list a physician or health care provider who is employed, owned or controlled by the employer or the employer's insurer unless the employment, ownership or controlling relationship is disclosed on the panel list.

3. You are required under the Pennsylvania WC Act to seek treatment from one of the health care providers on your employer's panel list for a period of ninety (90) days from the date of your first visit if your injury necessitates treatment. During the 90 day period, you may continue to visit the same or another listed health care provider.

4. Should you fail to comply with the foregoing, your employer will be relieved from responsibility for payment of services provided during the applicable 90 day period. Expenses incurred will be your responsibility regardless of relatedness to the compensable accident.

5. It is your employer's responsibility to provide you with written notification of your rights and duties under the Pennsylvania Workers' Compensation Act. This form serves as written notification and fulfills that responsibility.

6. Your employer shall ensure that you have been informed of and understand these rights and duties.

7. Your signature on this document will give satisfactory evidence that you have been informed and understand your rights and duties as an employee in the event of a work-related injury.

8. The failure of your employer to provide and evidence such notification shall relieve you from any notification duty owed, notwithstanding any provision of the Act to the contrary, and the employer shall remain liable for all treatment stemming from a compensable work-related injury.

9. Subsequent treatment, after the ninety (90) day period, may be provided by any health care provider of your choice.

10. In the event that invasive surgery is prescribed by a designated health care provider or physician, you are permitted to receive an additional opinion from any health care provider of your choice. If the additional opinion differs from that of the designated provider or physician, you may select your preferred course of treatment. However, if you elect to subscribe to the course of treatment recommended by the non-panel provider, you will be required to seek that course of treatment from a designated provider for ninety (90) days from the date of your visit to the physician or health care provider of your choice. Failure to do so will relieve your employer from liability for payment of services rendered during that period.

11. Following the termination of the ninety (90) day period, if you receive treatment of any kind from a non-designated health care provider, it is your responsibility to notify your employer within five (5) days of the initial treatment that you are treating with a non-designated provider.

12. Failure to properly notify your employer of care by a non-designated provider within the five (5) day time frame will relieve your employer from liability for payment of services rendered by that provider prior to notice if such services are determined to have been unreasonable or unnecessary.

13. In addition to payment of health care services as previously provided, your employer shall provide payment for medicines and supplies, hospital treatment, services and supplies and orthopedic appliances and prostheses in accordance with the Act.

14. Within thirty (30) days of returning to work and/or receiving any type of wages, it is your responsibility to notify your employer's insurance company of your change in work status. You must identify your employer, the date on which you returned to work and the job duties to which you have returned.

15. Willful or knowing violations of the Pennsylvania WC Act with the intent to defraud may result in the imposition of fines ranging from $5,000 - $15,000 in addition to criminal and/or civil charges.