To All Employees:

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:
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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.
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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:
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•
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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.
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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)