DCNR Workers Comp Forms

Commonwealth EMPLOYEE

Workers' Compensation Information

To: All Commonwealth Employees

The workers' compensation law in Pennsylvania provides wage loss and medical benefits to employees who cannot work and/or who need medical care because of a work-related injury.

Workers’ compensation benefits for employees of the Commonwealth of Pennsylvania are required to be paid by the commonwealth through its claims administrator, CompServices, Inc. The commonwealth is required to post the name of the company responsible for paying workers' compensation benefits at its primary place of business and at its sites 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. CompServices, Inc. has offices located at PO Box 8862, Camp Hill, PA 17001, telephone number 1-800-719-2889 and PO Box 535370, Pittsburgh, PA 15253, telephone number 1-888-871-3606.

You should report immediately any injury or work-related illness to your employer/supervisor. Your workers’ compensation benefits could be delayed or denied if you do not notify your employer/ supervisor immediately. Your Workers’ Compensation Coordinator is located within the Bureau of Human Resources, DCNR, PO Box 8768, Harrisburg, PA 17105-8768, (717) 783-5782.

If your work-related injury claim is denied, you have the right to file a petition and request a hearing before a workers' compensation judge.

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 Pennsylvania (717) 772-4447
TTY (800) 362-4228 (for hearing and speech impaired only)
www.state.pa.us  - PA Keyword: workers comp

EMPLOYEE ACKNOWLEDGMENT:

Please sign and date below to certify that you have received, read and understood the information provided above. Retain one copy for your records and return the original to your Human Resources Office.

NOTIFICATION TO EMPLOYEES OF THEIR RIGHTS AND DUTIES UNDER SECTION 306 (f.1)(1)(i) OF THE PA. WORKERS’ COMPENSATION ACT

The Pennsylvania Workers’ Compensation Act requires that employees be given written notification of their rights and duties under Sec. 306 (f.1)(1)(i) of the Act if a list of designated health care providers is established by the employer. Below are your rights and duties under Sec. 306 (f.1)(1)(i) and an acknowledgment signature line. This acknowledgment, signed by you, is to be returned to your employer.

A brief summary: You have the right to seek emergency medical treatment from any provider; for post-emergency and other injuries, you must obtain treatment for work-related injuries and illnesses from a designated health care provider for 90 days. The penalty for not using a designated health care provider is that your employer is not liable for the medical bills incurred.

As an employee of the Commonwealth working at a location where a list of designated health care providers has been established and posted, you have:

• The duty to obtain treatment for work-related injuries and illnesses from one or more of the designated health care providers for 90 days from the date of the first visit to a designated provider.

• The right to seek emergency medical treatment from any provider, but subsequent non-emergency treatment shall be by a designated provider for the remainder of the 90-day period.

• The right to have all reasonable medical supplies and treatment related to the injury paid for by your employer as long as treatment is obtained from a designated provider during the 90-day period. 

• The right, during this 90-day period, to switch from one designated health care provider to another designated provider.

• The right to seek treatment from a provider if you are referred to that provider by a designated provider.

• The right to an additional opinion from a provider of your choice when invasive surgery is prescribed by the designated provider.

• The right to seek treatment or medical consultation from a non designated provider during the 90-day period, but the services shall be at your expense for the applicable 90 days.

• The right to seek treatment from any health care provider after the 90-day period has ended.

• The duty to notify your employer of treatment by a non designated provider (after the 90 day period) within 5 days of the first visit to that provider. The employer may not be required to pay for treatment rendered by a non designated provider prior to receiving this notification.

I acknowledge that I have been informed of my rights and duties

under Sec. 306 (f.1)(1)(i) and that I understand them

to the extent that they are explained above.

See reverse for a complete text of Section 306 (f.1)(1)(i)

If you have any questions, ask your human resources office representative or call

The Bureau of Workers’ Compensation at 1-800-482-2383

PENNSYLVANIA WORKERS’ COMPENSATION ACT
SECTION 306 (f.1)(1)(i) 

The employer shall provide payment in accordance with this section for reasonable surgical and medical services, services rendered by physicians or other health care providers, including an additional opinion when invasive surgery may be necessary, medicines and supplies, as and when needed. Provided an employer establishes a list of at least six designated health care providers, no more than four of whom may be a coordinated care organization and no fewer than three of whom shall be physicians, the employee shall be required to visit one of the physicians or other health care providers so designated and shall continue to visit the same or another designated physician or health care provider for a period of ninety (90) days from the date of the first visit: provided, however, that the employer shall not include on the list a physician or other health care provider who is employed, owned or controlled by the employer or the employer’s insurer unless employment, ownership or control is disclosed on the list. Should invasive surgery for an employee be prescribed by a physician or other health care provider so designated by the employer, the employee shall be permitted to receive an additional opinion from any health care provider of the employee’s own choice. If the additional opinion differs from the opinion provided by the physician or health care provider so designated by the employer, the employee shall determine which course of treatment to follow: provided, that the second opinion provides a specific and detailed course of treatment. If the employee chooses to follow the procedures designated in the second opinion, such procedures shall be performed by one of the physicians or other health care providers so designated by the employer for a period of ninety (90) days from the date of the visit to the physician or other health care provider of the employee’s own choice. Should the employee not comply with the foregoing, the employer will be relieved from liability for the payment for the services rendered during such applicable period. It shall be the duty of the employer to provide a clearly written notification of the employee’s rights and duties under this section to the employee. The employer shall further ensure that the employee has been informed and that he understands these rights and duties. This duty shall be evidenced only by the employee’s written acknowledgment of having been informed and having understood his rights and duties. Any failure of the employer to provide and evidence such notification shall relieve the employee from any notification duty owed, notwithstanding any provision of this act to the contrary, and the employer shall remain liable for all rendered treatment. Subsequent treatment may be provided by any health care provider of the employee’s own choice. Any employee who, next following termination of the applicable period, is provided treatment from a nondesignated health care provider shall notify the employer within five (5) days of the first visit to said health care provider. Failure to so notify the employer will relieve the employer from liability for the payment for the services rendered prior to appropriate notice if such services are determined pursuant to paragraph (6) to have been unreasonable or unnecessary.