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PANEL OF PHYSICIANS SAMPLE

If you are injured while at work and medical treatment is necessary, you are required to visit one of the physicians or health care providers on the list posted at your worksite. This treatment must be for a period of 90 days from your first visit with the physician or health care provider. During the 90 day period, you may change from one designated physician or health care provider on the list to another physician or health care provider on the list, and the treatment will be paid for by the employer. If the designated physician or health care provider refers you to a non-designated provider, the employer will pay for the treatment by the non-designated provider.

You have the right to obtain emergency medical treatment from a non-designated physician or health care provider however, the subsequent non-emergency treatment must be by a designated physician or health care provider for the remainder of the 90 day period.

All reasonable medical treatment and supplies (e.g. medicines, prosthetics) related to the injury will be paid for by the employer provided treatment is by a designated physician or health care provider on the list during the 90 day period. Charges for treatment and supplies are specified by the ACT. You are not responsible for the payment of any charges in excess of those specified by the ACT.

You may seek treatment or consultation from a non-designated physician or health care provider during the initial 90 day period however, you are responsible for the charges for this treatment during the 90 day period. You have the duty to notify your employer of treatment by a non-designated physician or health care provider within 5 days of your first visit to this physician or provider. Your employer may not be required to pay for treatment by a non-designated physician or health care provider prior to notification.

If the employer designated physician or health care provider recommends invasive surgery, you are permitted to obtain a second opinion from a non-designated physician or health care provider. Your employer will pay for the cost for this opinion. If this opinion differs from the opinion of the designated physician or health care provider and provides a specific and detailed course of treatment, you may elect to undergo this treatment. A designated physician or health care provider however must provide the treatment for 90 days from the date of the visit to the non-designated physician.

You have the right to seek treatment from any physician or health care provider after the 90 day period has ended, and your employer will pay for this treatment provided it is reasonable and necessary.