Dear Policyholder, You have purchased Workersâ€™ Compensation

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8665715042

FAX 6197445030

CA License 2C37446

Dear Policyholder

You have purchased Workersrsquo Compensation Insurance through

Arrowhead General Insurance Agency Your carrier has

partnered with American Claims Management (ACM) a

subsidiary of Arrowhead General Agency to provide you with

workersrsquo compensation claims services

It is our goal to make your transition to ACM as smooth and

seamless as possible and to provide claim services that are in-

sync with the intricacies of your business

Attached please find your introductory claims kit This package

includes directions on how to file a claim in the event that an

injury occurs as well as how to implement the Medical Provider

Network (MPN) for your employees

For your convenience all forms are available online at our

website wwwACMClaimscom On ACMrsquos home page navigate

to the Policy Holder tab on the right hand side of the screen

Select Workersrsquo Compensation as the Line of Business and you will

then be directed to the Workersrsquo Compensation site Select

Forms There the Policy Holder Kit and other useful forms such as

the Claims Form (DWC1) will be available to save or print

In addition the Medical Provider Network can be found online at

our website wwwACMClaimscom From the Workersrsquo

Compensation site select Medical Provider Network (MPN) By

clicking on the appropriate network you will be able to find a

MPN facility or doctor close to your business or employeersquos home

to send your employee to seek care

ACM will work together with you to make sure that you have all

the information you need to communicate this change to your

employees Let me know if you have any questions or need any

further information

We look forward to helping you manage your workersrsquo

compensation program

Regards

American Claims Management Inc

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8887992919

FAX 7608274040

CA License 2C37446

How to Report a Work-Related Injury

When an employee has been injured at work how do you take control of the

situation Follow these three easy steps to immediately file your claim

If the event is a medical emergency seek immediate care for the employee from the

nearest emergency medical provider or facility For non emergencies your Medical

Provider Network is the American Claims Management MPN You can access the

medical provider network for your injured employees by going to our website at

wwwACMClaimscom or call the MPN Help Desk at (866) 671-5042

Report a Claim 24 hrs7 days

Online ACMClaimscom (Preferred)

Phone 866-671-5042

Fax 619-744-5030

Email reportaclaimacmclaimscom

Distribute to the Injured Employee at Time of Injury

Form DWC-1

Facts About Workers Compensation

Initial Written Employee Notification Re MPN

1 Get The Facts 2 Gather All Supporting

Information

3 Report the Claim

Immediately

Find out as much as you

can about the injury and

obtain the employeersquos

personnel file whenever

possible

Obtain as much supplemental

information as you can before you

report the claim

bull Name Address Phone

bull Date of Birth

bull Social Security Number

bull Date of Hire

bull Wage Information

Donrsquot delay in calling

because you donrsquot have all

the information Timely

reporting is essential You can

gather and report any missing

information at a later date

ACMclaimscom

701 B Street Suite 2100

San Diego CA 92101

TOL 8887992919

FAX 7608274040

CA License 2C37446

Helpful Contact Information

How to Report a Claim

Via Phone - 866-671-5042

Via Fax - 619-744-5030

Via Email ndash Reportaclaimacmclaimscom

Via Internet ndash wwwacmclaimscom

How to Request a Claims Kit

Email ndash wcinfoacmclaimscom

Medical Provider Network (MPN) Information

MPN Provider Search wwwACMClaimscom

MPN Help Desk ACMMPNACMClaimscom

Additional Inquiries

Bill Review Help Desk billreviewacmclaimscom

Loss Run Requests lrrarrowheadgrpcom

General Questions wcinfoacmclaimscom

ACMrsquos Mailing Address

PO Box 85251

San Diego CA 92186

ACMrsquos Contact Numbers

Toll Free Number 866-671-5042

Fax Number 619-744-5030

If you are injured or become ill either physically or mentally becauseof your job including injuries resulting from a workplace crime youmay be entitled to workersrsquo compensation benefits Attached is the formfor filing a workersrsquo compensation claim with your employer Youshould read all of the information below Keep this sheet and all otherpapers for your records You may be eligible for some or all of thebenefits listed depending on the nature of your claim If required youwill be notified by the claims administrator who is responsible forhandling your claim about your eligibility for benefits

To file a claim complete the ldquoEmployeerdquo section of the form keep onecopy and give the rest to your employer Your employer will thencomplete the ldquoEmployerrdquo section give you a dated copy keep one copyand send one to the claims administrator Benefits canrsquot start until theclaims administrator knows of the injury so complete the form as soonas possible

Medical Care Your claims administrator will pay all reasonable andnecessary medical care for your work injury or illness Medical benefitsmay include treatment by a doctor hospital services physical therapylab tests x-rays and medicines Your claims administrator will pay thecosts directly so you should never see a bill There is a limit on somemedical services

The Primary Treating Physician (PTP) is the doctor with the overallresponsibility for treatment of your injury or illness Generally youremployer selects the PTP you will see for the first 30 days however inspecified conditions you may be treated by your predesignated doctoror medical group If a doctor says you still need treatment after 30 daysyou may be able to switch to the doctor of your choice Different rulesapply if your employer is using a Health Care Organization (HCO) or aMedical Provider Network (MPN) A MPN is a selected network ofhealth care providers to provide treatment to workers injured on the jobYou should receive information from your employer if you are coveredby an HCO or a MPN Contact your employer for more information Ifyour employer has not put up a poster describing your rights to workersrsquocompensation you may choose your own doctor immediately

Within one working day after you file a claim form your employer shallauthorize the provision of all treatment consistent with the applicabletreating guidelines for the alleged injury and shall continue to be liablefor up to $10000 in treatment until the claim is accepted or rejected

Disclosure of Medical Records After you make a claim for workersrsquocompensation benefits your medical records will not have the samelevel of privacy that you usually expect If you donrsquot agree to voluntarilyrelease medical records a workersrsquo compensation judge may decidewhat records will be released If you request privacy the judge mayldquosealrdquo (keep private) certain medical records

Payment for Temporary Disability (Lost Wages) If you canrsquot workwhile you are recovering from a job injury or illness for most injuriesyou will receive temporary disability payments for a limited period oftime These payments may change or stop when your doctor says youare able to return to work These benefits are tax-free Temporarydisability payments are two-thirds of your average weekly pay withinminimums and maximums set by state law Payments are not made forthe first three days you are off the job unless you are hospitalizedovernight or cannot work for more than 14 days

Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a sutrabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo esposible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Seadjunta el formulario para presentar un reclamo de compensacioacuten de trabajadorescon su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guardeesta hoja y todos los demaacutes documentos para sus archivos Es posible que ustedreuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumerandependiendo de la iacutendole de su reclamo Si se requiere el administrador dereclamos quien es responsable por el manejo de su reclamo le notificaraacute sobresu elegibilidad para beneficios

Para presentar un reclamo llene la seccioacuten del formulario designada para elldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Entonces suempleador completaraacute la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Uduna copia fechada guardaraacute una copia y enviaraacute una al administrador dereclamos Los beneficios no pueden comenzar hasta que el administrador dereclamos se entere de la lesioacuten asiacute que complete el formulario lo antes posible

Atencioacuten Meacutedica Su administrador de reclamos pagaraacute toda la atencioacuten meacutedicarazonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Esposible que los beneficios meacutedicos incluyan el tratamiento por parte de unmeacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio y lasmedicinas Su administrador de reclamos pagaraacute directamente los costos demanera que usted nunca veraacute un cobro Hay un liacutemite para ciertos serviciosmeacutedicos

El Meacutedico Primario que le Atiende-Primary Treating Physician PTP es elmeacutedico con la responsabilidad total para tratar su lesioacuten o enfermedadGeneralmente su empleador selecciona al PTP que Ud veraacute durante los primeros30 diacuteas Sin embargo en condiciones especiacuteficas es posible que usted pueda sertratado por su meacutedico o grupo meacutedico previamente designado Si el doctor diceque usted auacuten necesita tratamiento despueacutes de 30 diacuteas es posible que Ud puedacambiar al meacutedico de su preferencia Hay reglas differentes que se aplican cuandosu empleador usa una Organizacioacuten de Cuidado Meacutedico (HCO) o una Red deProveedores Meacutedicos (MPN) Una MPN es una red de proveedores de asistenciameacutedica seleccionados para dar tratamiento a los trabajadores lesionados en eltrabajo Usted debe recibir informacioacuten de su empleador si su tratamiento escubierto por una HCO o una MPN Hable con su empleador para maacutesinformacioacuten Si su empleador no ha colocado un cartel describiendo sus derechospara la compensacioacuten de trabajadores Ud puede seleccionar a su propio meacutedicoinmediatamente

Dentro de un diacutea despueacutes de que Ud Presente un formulario de reclamo suempleador autorizaraacute todo tratamientomeacutedico de acuerdo con las pautas detratamiento aplicables a la presunta lesioacuten y seraacute responsable por $10000 entratamiento hasta que el reclamo sea aceptado o rechazado

Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamopara beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos notendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud noestaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez decompensacioacuten de trabajadores posiblemente decida queacute expedientes se revelaraacutenSi Ud solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados)ciertos expedientes meacutedicos

Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajarmientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con eltrabajo Ud recibiraacute pagos por incapacidad temporal para la mayoriacutea de laslesions por un period limitado Es posible que estos pagos cambien o parencuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estosbeneficios son libres de impuestos Los pagos por incapacidad temporal son dostercios de su pago semanal promedio con cantidades miacutenimas y maacuteximasestablecidas por las leyes estatales Los pagos no se hacen durante los primeros

Workerrsquos Compensation Claim Form (DWC 1) amp Notice of Potential EligibilityFomulairo de Recclamo de Compensacioacuten par Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad

ACM DWC Form 1 910 9910 127 PM

tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche ono pueda trabajar durante maacutes de 14 diacuteas

Regreso al Trabajo Para ayudarle a regresar a trabajar lo antes posible Ud debecomunicarse de manera activa con el meacutedico que le atienda el administrador dereclamos y el empleador con respecto a las clases de trabajo que Ud puede hacermientras se recupera Es posible que ellos coordinen esfuerzos para regresarle aun trabajo modificado o a otro trabajo que sea apropiado desde el punto de vistameacutedico Este trabajo modificado u otro trabajo podriacutea ser temporal o podriacuteaextenderse dependiendo de la iacutendole de su lesioacuten o enfermedad

Pago por Incapacidad Permanente Si el doctor dice que su lesioacuten oenfermedad resulta en una incapacidad permanente es posible que Ud recibapagos adicionales La cantidad dependeraacute de la clase de lesioacuten su edad suocupacioacuten y la fecha de la lesioacuten

Beneficio Suplementario por Desplazamiento de Trabajo Si Ud Se lesionoacutedespueacutes del 1104 y tiene una incapacidad permanente que le impide regresar altrabajo dentro de 60 diacuteas despueacutes de que los pagos por incapacidad temporalterminen y su empleador no ofrece un trabajo modificado o alternativo esposible que usted reuacutena los requisitos para recibir un vale no-transferiblepagadero a una escuela para recibir un nuevo entrenamiento yo mejorar suhabilidad Si Ud reuacutene los requisitios el administrador de reclamos pagaraacute losgastos hasta un maacuteximo establecido por las leyes estatales basado en suporcentaje de incapacidad permanente

Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posibleque los pagos se hagan a los parientes o a las personas que viven en el hogar yque dependiacutean econoacutemicamente del trabajador difunto

Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten oenfermedad en el trabajo por presentar un reclamo o por testificar en el caso decompensacioacuten de trabajadores de otra persona (El Codigo Laboral seccioacuten 132a)De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten deltrabajo aumento de beneficios y gastos hasta los liacutemites establecidos por elestado

Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamoSi Ud tiene un desacuerdo primero comuniacutequese con su administrador dereclamos para ver si usted puede resolverlo Si usted no estaacute recibiendobeneficios es posible que Ud pueda obtener beneficios del Seguro Estatal deIncapacidad (SDI) Llame al Departamento Estatal del Desarrollo del Empleo(EDD) al (800) 480-3287

Ud puede obtener informacioacuten gratis de un oficial de informacioacuten y asistenciade la Divisioacuten Estatal de Compensacioacuten de Trabajadores (Division of WorkersrsquoCompensation ndash DWC) o puede escuchar informacioacuten grabada asiacute como una listade oficinas locales llamando al (800) 736-7401 Ud tambieacuten puede consultar conla pagiacutena Web de la DWC en wwwdwccagov

Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen unaconsulta gratis Si Ud decide contratar a un abogado los honorarios seraacutentomados de algunos de sus beneficios Para obtener nombres de abogados decompensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados deCalifornia (State Bar) al (415) 538-2120 oacute consulte con la pagiacutena Web enwwwcaliforniaspecialistorg


Return to Work To help you to return to work as soon as possible youshould actively communicate with your treating doctor claimsadministrator and employer about the kinds of work you can do whilerecovering They may coordinate efforts to return you to modified dutyor other work that is medically appropriate This modified or other dutymaybe temporary or may be extended depending on the nature of yourinjury or illness

Payment for Permanent Disability If a doctor says your injury or illness results in a permanent disability you may receive additional payments The amount will depend on the type of injury your age occupation and date of injury

Supplemental Job Displacement Benefit (SJDB) If you were injured after 1104 and you have a permanent disability that prevents you from returning to work within 60 days after your temporary disability endsand your employer does not offer modified or alternative work you may qualify for a nontransferable voucher payable to a school for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law based on your percentage of permanent disability

Death Benefits If the injury or illness causes death payments may be made to relatives or household members who were financiallydependent on the deceased worker

It is illegal for your employer to punish or fire you for having a jobinjury or illness for filing a claim or testifying in another personrsquosworkersrsquo compensation case (Labor Code 132a) If proven you mayreceive lost wages job reinstatement increased benefits and costs andexpenses up to limits set by the state

You have the right to disagree with decisions affecting your claim If you have a disagreement contact your claims administrator first to see ifyou can resolve it If you are not receiving benefits you may be able toget State Disability Insurance (SDI) benefits Call State EmploymentDevelopment Department at (800) 480-3287

You can obtain free information from an information and assistanceofficer of the State Division of Workersrsquo Compensation (DWC) or youcan hear recorded information and a list of local offices by calling (800)736-7401 You may also go to the DWC website at wwwdwccagov

You can consult with an attorney Most attorneys offer one freeconsultation If you decide to hire an attorney his or her fee will betaken out of some of your benefits For names of workersrsquo compensation attorneys call the State Bar of California at (415) 538-2120 or go totheir web site at wwwcaliforniaspecialistorg

ACM DWC Form 1 910 9910 127 PM Page 2

State of CaliforniaDepartment of Industrial RelationsDIVISION OF WORKERSrsquo COMPENSATION

Estado de CaliforniaDepartmento of Relaciones Industriales

DIVISION DE COMPENSACIOacuteN AL TRABAJADOR

WORKERrsquo COMPENSATION CLAIM FORM (DWC 1) PETITION DEL EMPLEADO PARA DE COMPENSACIacuteON DELTRABAJADOR (DWC 1)

Employee Complete the ldquoEmployeerdquo section and give the form to youremployer Keep the a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo untilyou receive the signed and dated copy from your employer You may call theDivision of Workersrsquo Compensation and hear recorded information at (800)736-7401 An explanation of workersrsquo compensation benefits is included as thecover sheet of this form

You should also have received a pamphlet from your employer describingworkersrsquo compensation benefits and the procedures to obtain them

Any person who makes or causes to be made any knowingly false orfradulent material statement or material representation for the purposeof obtaining or denying workersrsquo compensation benefits or payments isguilty of a felony

Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue laforma a su empleador Queacutedese con la copia designada ldquoReciboTemporal del Empleadordquo hasta que UD reciba la copia firmaday fechada de su empleador Ud puede llamar a la Division deCompensacioacuten al Trabajador al (800) 736-7401 para oirinformacioacuten gravada En la hoja cubierta de esta forma esta laexplicacioacuten de los beneficios de compensacioacuten al trabajador

Ud tambieacuten deberiacutea haber recibido de su empleador unfolleto describiendo los beneficios de compensacioacuten al trabajadorlesionado y los procedimientos para obtenerlos

Toda aquella persona que a propoacutesito haga o cause que se produzcacualquier declaracioacuten o representacioacuten material falsa o fraudulenta conel fin de obtener o negar beneficios o pagos de compensacioacuten atrabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo

Employee ndash complete this section and see note above Empleado ndash complete esta seccioacuten y note la notacioacuten arriba

1 Name Nombre _________________________________________________________ Todayrsquos Date Fecha de hoy _____________________________________

2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________

3 City Ciudad _______________________________________________________ State Estado _____________________ Zip Coacutedigo Postal ________________

4 Date of Injury Fecha de la lesioacuten (accidente) __________________________ Time of Injury Hora en que ocurrioacute ________________ am ___________ pm

5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente __________________________________________________

________________________________________________________________________________________________________________________________________

6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ________________________________________________________

________________________________________________________________________________________________________________________________________

7 Social Security Number Nuacutemero de Seguro Social del Empleado _____________________________________________________________________________

8 Signature of employee Firma del empleado ________________________________________________________________________________________________

Employer ndash complete this section and see note below Empleado ndash complete est seccioacuten y note la notacioacuten abajo

9 Name of employer Nombre del empleador _________________________________________________________________________________________________

10Address Direccioacuten ______________________________________________________________________________________________________________________

11Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ______________________________________

12Date claim form was provided to employee Fecha en que se le entregoacute al empleado las peticioacuten _________________________________________________

13Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador _________________________________________________

14Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de sequros o agencia administradora de seguros _____

________________________________________________________________________________________________________________________________________

15 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro __________________________________________________________________________________

16Signature of employer representative Firma del representante del empleador __________________________________________________________________

17Title Tiacutetulo ________________________________________________________ 18 Telephone Teleacutefono ______________________________________________

Employer You are required to date this form and provide copies to your insureror claim administrator and to the employee dependent or representative whofiled the claim within one working day of receipt of the form from the employee

SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY

Empleador Se require que Ud feche esta forma y que proveacutea copias a sucompantildeiacutea de seguros administrador de reclamos o dependienterepresentantede reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazode un diacutea haacutebil desde el momento de haber sido recibida la forma delempleadoEL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD

DWC Form 1 (Rev 610) DWC Forma 1 (Rev 610)

AMERICAN CLAIMS MANAGEMENT INC bull PO BOX 85251 bull SAN DIEGO CA 92186


State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS

Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony

California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health

EMPLOYER

6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify

17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)

18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE

INJURY

21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)

Yes No

22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No

OR

ILLNESS

PART OF BODY

ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2

EMPLOYEE

35 OCCUPATION (Regular job title NO initials abbreviations or numbers)

37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED

37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time

part-time

EXTENT OF INJURY

total weekly hoursdays per weekhours per daytemporary seasonal

39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No

Date (mmddyy)Signature amp TitleCompleted By (type or print)

bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies

FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY

OSHA CASE NO

FATALITY

1 FIRM NAME Ia Policy Number

2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number

3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code

4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno

Please do not usethis column

CASE NUMBER

OWNERSHIP

INDUSTRY

OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)

8 TIME INJURYILLNESS OCCURREDPMAM

9 TIME EMPLOYEE BEGAN WORKPMAM

10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)

1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY

Yes No

12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX

DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY

24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold

25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck

26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY

SOURCE

EVENT

SECONDARY SOURCE

Elsa Q Gomez

Facts About Workersrsquo Compensation The content of this pamphlet has been approved by the Administrative Director of the Division of Workersrsquo Compensation

WHAT IT ISCalifornia workersrsquo compensation law provides a faster and fairer way to take care of injured workers where fault doesnrsquot have to be proven to recover medical expenses and lost wages This job-injury insurance is paid for by your employer and supervised by the State If you canrsquot work due to a job-related injury or illness workersrsquo compensation pays your medical bills and provides money to help replace lost wages until you can return to work

WHOrsquoS COVEREDAlmost every employee in California is protected by workersrsquo compensation but there are few exceptions People in business for themselves and unpaid volunteers may not be covered Maritime workers and federal employees are covered by similar laws If you have a question about coverage ask your employer

WHATrsquoS COVEREDAlmost any injury or illness is covered if itrsquos due to your job It can be caused by one event like a fall or repeated exposures such as repetitive motion over time Everything from minor injuries to serious accidents is covered Workersrsquo compensation even covers injuries- including physical or psychiatric injuries- resulting from a work-place crime (Some injuries from voluntary off-duty recreational social or athletic activity- for example the company bowling team ndash may not be covered Check with your supervisor or American Claims Management Workersrsquo Compensation Office at 8666715042 if you have questions)Coverage is automatic and immediate There is no qualifying period no need to earn a certain amount in wages before yoursquore covered Protection begins the first minute yoursquore on the job

HOW TO REPORT AN INJURYImmediately report to your supervisor any injury no matter how slight You can also report the injury to ACM online at ACMclaimscom or by phone at 8666715042 You should also complete the State required Claim Form (DWC 1) and return to your supervisor or to ACM If you are in need of the Claim Form (DWC 1) you may obtain a copy on the ACM Web site ACMclaimscom under FormsState law requires employers to authorize medical care within one working day of receiving a claim form and employers may be liable for as much as $10000 in treatment until a claim is accepted or rejected

HOW TO OBTAIN MEDICAL CARE First Aid Seek first-aid treatment immediately either on site at work or at the designated medical treatment facility Emergency Care Seek medical treatment immediately See the emergency telephone numbers which should also be posted in your workplace Emergency Telephone Number Call 911 for an ambulance the fire department police or for emergency medical care from a doctor or the hospital or go to the nearest emergency roomAcute and Follow Up Care If you appropriately pre-designated your personal physician contact your physician as soon as possible and make arrangements for treatment OR If you did not pre-designate your personal physician call ACM at 8666715042 as soon as possible to help you make arrangement for treatment State law requires employers to authorize medical treatment within one working day of receiving the completed Claim Form from you If you delay reporting your injury or delay completing the Claim Form it may result in a delay in receiving benefits and too long a delay may even jeopardize your right to obtain benefits all together

MORE ABOUT MEDICAL CAREQuality medical treatment is the quickest way to recovery Primary Treating Physician (PTP) The doctor with the overall responsibility for your treatment is the primary treating physician (PTP) The PTP decides what kind of medical care you need and when you can return to work If necessary the PTP will review your job description and will define any limitations or restrictions that you may have when you go back to work The PTP will coordinate any care you receive from other medical providers and for a serious injury will write reports about any permanent disability or need for future medical care One Time Right to Change PTP You have the right to change your PTP one time You can request this change at any time Change of PTP First 30 Days If you make your request to change PTP during the first 30 days after reporting your injury you can change to your personal chiropractor or acupuncturist if you have pre-designated this physician Change of PTP After 30 Days If you have not already used your one-time change of PTP then thirty (30) days after reporting your injury you may change to the PTP of your own choice This can be your personal medical doctor or osteopath your personal chiropractor person acupuncturist or physician of your choice within a reasonable geographic area Personal Physician (MD or DO) If you have a personal physician who is a medical doctor (ldquoMDrdquo) or osteopath (ldquoDOrdquo) and you wish to designate this physician to be your PTP you must do so in writing prior to the injury occurring The physician

OPTIONAL FORMPREDESIGNATION OF PERSONAL PHYSICIANIn 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 (MD) doctor of osteopathic medicine (DO) or medical group if bull Your employer offers group health coverage bull The doctor is your regular physician who shall be either a physician who had 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 recordsbull Your ldquopersonal physicianrdquo may be a medical group if it is a single corporation partnership composed of licensed doctors of medicine or osteopathy which operates an integrated multi-specialty medical group providing comprehensive medical services predominantly for non-occupational illnesses and injuries bull Prior to the injury your doctor agrees to treat you for work injuries or illnessesbull 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 doctorrsquos name and business addressYou 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 PHYSICIANEmployee Complete this section

To (name of employer)

If I have a work-related injury or illness I choose to be treated by

Doctor

Street Address City State Zip

Telephone

Employee Name

Employee Address

Employee Signature

Date

(Physician or Designation 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 physicianrsquos agreement to be predesignated will be required pursuart to Title 8 California Code of Regulations section 9780 1(a)(3)

Title 8 California Code of Regulations section 9783 DWC Form 9783 (March 1 2007)

Note to Employee Unless an employee agrees neither the employer nor ACM shall contact your personal physician to confirm a predesignation [CCR 97801(f)] If your physician does not sign the above form other documentation of hisher predesignation will be required prior to an injury being sustained If you agree that after receiving this form your employer or ACM may contact your physician to confirm the predesignation please sign below

Employee Signature

Employee ID

Date

Note to Physician Workersrsquo compensation medical services are subject to preauthorization of non-emergency services utilization review reporting requirements and the California Official Medical Fee Schedule The following optional information may assist communication and facilitate the authorization reporting recordkeeping and payment process

Office ManagerBilling Contact

Phone Number

Mailing Address (if different from street address)

Fax

Email

Physician License

Physician Tax ID

must agree to treat you for a work-related injury or illness prior to the injury Medical Provider Network (MPN) Since a MPN is offered by your employer a network doctor will generally be your PTP for the duration of treatment though you may switch to another doctor in the network anytime after your first visit If you want to switch to a chiropractor or acupuncturist including a personal chiropractor or personal acupuncturist named prior to the injury he or she must be in the network Your employer or ACM can provide additional information about the network and your rights under your plan

BENEFITSMedical Care Medical expenses for reasonable and necessary treatment will be paid directly by ACM on behalf of your employer Medical bills for authorized care should never be received or paid by you All bills should be sent to American Claims Management at PO Box 85251 San Diego CA 92186 There is a limit on some medical servicesTemporary Disability If you are unable to work for more than three days including weekends you are entitled to temporary disability (TD) payments to help replace your lost wages About two weeks after reporting the injury yoursquoll receive a check from ACM You will continue to receive TD checks every two weeks after that until the doctors says that you can return to work or that your medical condition is ldquopermanent and stationaryrdquo (Payments will not be made for the first three days however unless yoursquore hospitalized as an inpatient or unable to work more than 14 days) The amount of these checks will be two-thirds of your average wage subject to minimums and maximums set by State law There are no deductions and the payments are tax free Under California law TD payments for a single injury may not extend for more than 104 compensable weeks within five years from the date of the injury or for more than 240 weeks within five years from the date of injury for certain specified long-term injuries such as severe burns or chronic lung disease If the maximum TD payment period is reached before you can return to work or before your medical condition becomes permanent and stationary you may be able to obtain disability benefits through the California Employment Development Department (EDD) You may also be able to receive these benefits if your TD is delayed or denied Permanent Disability If your doctor says your injury or illness will result in permanent limitations or restrictions in your ability to work you may receive permanent disability payments The amount depends on the doctorrsquos report how much of the permanent disability was directly caused by your work and factors such as your age occupation type of injury and date of injury Your benefit payment also may be affected by whether or not your employer makes a suitable return-to-work offer and whether or not you accept the offer The minimum and maximum amounts are set by State law but if you have a permanent disability ACM will send a letter explaining how the benefit was calculated In general the total amount

is set at a weekly rate spread over a fixed number of weeks The first payment is due within 14 days after the final temporary disability payment or if you were not receiving temporary disability payments 14 days after your doctor says your condition is permanent and stationary After that the benefit will be paid every 14 days until you reach the maximum or until you settle your case and receive a lump sum payment Death Benefits If the injury or illness causes death payments may be made to individuals who were financially dependent on you These benefits are set by State law and the amount depends on the number of dependents and the date of injury Workersrsquo compensation also provides a burial allowance Supplemental Job Displacement Benefit Once ACM receives a doctorrsquos report that you have recovered as much as possible from your job injury and your injury results in permanent disability within 60 days ACM will send a letter advising you whether your employer has a modified job or alternative work available to you If your employer does not offer modified or alternative work ACM has 20 days to offer you the Supplemental Job Displacement Benefit This is a $6000 non transferrable voucher that is to be used at a State accredited school for education-related retraining or skill enhancement There are limits to how much you can spend for some items but if you qualify yoursquoll get information on what types of expenses are covered the limits documentation requirements and deadlines for use of this benefit Other Benefits To clarify Workersrsquo Compensation insurance covers on-the-job injuries and illnesses and is paid for entirely by your employer whereas State Disability insurance (SDI) covers off-the-job injuries or sicknesses and is paid for by deductions from your paycheck If you are not receiving workersrsquo compensation benefits you could be eligible to receive SDI benefits To learn more call the local state Employment Development Disability listed in the government pages of your phone book or on the web at wwwEDDcagovdisability If the state determines that your workersrsquo compensation permanent disability is too low compared to your loss of future earnings you may qualify for additional money from a Return-to-Work Fund approved by state lawmakers in 2012 This fund is administered by the Department of Industrial Relations details on eligibility and how to apply will be included in state regulations If you believe that you qualify contact the local DWC Information and Assistance office listed at your workplace or you can call 8007367401 or visit the Division of Workersrsquo Compensation web site at wwwDWCcagov

QUESTIONSYou may direct any and all questions to your supervisor or ACM ACMrsquos address and phone number is listed at the bottom of this document You can also contact an information and assistance officer at the State Division of Workersrsquo Compensation (DWC) Information and assistance officers are available at no charge to answer questions review problems and provide additional written information about workersrsquo compensation The local office is listed at the end of this document and is posted at your workplace or you can call 8007367401 check the local listing in the white pages of the phone book under State Government OfficeIndustrial RelationsWorkersrsquo Compensation or go to the DWC Web site at wwwdircagovdwc

WORKERSrsquo COMPENSATION FRAUD IS A FELONYAnyone who makes or causes to be made any knowingly false or fraudulent material statement for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony

Claims Administered by American Claims ManagementPO Box 85251San Diego CA 92186

Toll Free 8666715042ACMclaimscom

NON-DISCRIMINATION It is illegal for your employer to fire you or in any way discriminate against you because you file a claim intend to file a claim settle a claim testify or intend to testify for another injured worker If it is found that your employer discriminated against you your employer may be ordered to reinstate you to your job reimburse you for lost wages and employment benefits and pay increased workersrsquo compensation benefits costs and expenses up to maximum amounts set by state law

Anaheim (714) 414-1801

Bakersfield (661) 395-2514

Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389

Marina del Rey (310) 482-3820

Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347

Sacramento (916) 928-3158

Salinas (831) 443-3058

San Bernardino (909) 383-4522

San Diego (619) 767-2082

San Francisco (415) 703-5020

San Jose (408) 277-1292

San Luis Obispo (805) 596-4159

Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367

INFORMATION AND ASSISTANCE OFFICES

Facts About Workersrsquo Compensation

OPTIONAL FORMNOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST If your employer or your employerrsquos insurer does not have a Medical Provider Network you may be able to charge your treating physician to your personal chiropractor or acupuncturist following a work-related injury or illness In order to be eligible to make this change you must give your employer the name and business address of a personal chiropractor or acupuncturist in writing prior to the injury or illness Your claims administrator generally has the right to select your treating physician within the first 30 days after your employer knows of your injury or illness After your claims administrator has initiated your treatment with another doctor during this period you may then upon request have your treatment transferred to your personal chiropractor or acupuncturist You may use this form to notify your employer of your personal chiropractor or acupuncturist

Name of Chiropractor or Acupuncturist (DC LAc)


Telephone

Employee Name (please print)

Employeersquos Address

Employee Signature

Date


Note to Employee State law does not allow a chiropractor to be a treating physician beyond a maximum of 24 visits A personal chiropractor must be your regular licensed chiropractor (DC) who previously directed your treatment and retains your chiropractic treatment records including your chiropractic history A person acupuncturist must be your regular licensed acupuncturist (LAc) who previously directed your treatment and retains your acupuncture treatment records including your acupuncture historyIf your employer offers a workersrsquo compensation Medical Provider Network (MPN) you may only switch to a personal chiropractor or acupuncturist within the MPN If you are a member of a workersrsquo compensation Health Care Organization (HCO) different rules ap-ply so check with your employer or claims administrator if that is the case

simplified versions

secondary option

Informacioacuten Sobre Indemnizacioacuten por Accidentes de TrabajoQUEacute ES La legislacioacuten de California sobre Indemnizacioacuten por Accidentes de Trabajo brinda una manera

maacutes raacutepida y justa de atender a los empleados lesionados en casos en los cuales no haya que

probar culpa para recibir el reembolso de los gastos meacutedicos y el salario que el empleado no

ganoacute Este seguro por lesiones de trabajo estaacute pagado por el empleador y supervisado por

el Estado En caso de no poder trabajar debido a una lesioacuten o enfermedad de trabajo la

indemnizacioacuten laboral paga los gastos meacutedicos y brinda una entrada de dinero para reemplazar

el salario que se dejoacute de ganar hasta que el empleado regrese al trabajo

QUIEacuteN RECIBE COBERTURACasi todos los empleados de California estaacuten protegidos por la indemnizacioacuten laboral pero

existen algunas excepciones Es posible que las personas que trabajan por cuenta propia y los

voluntarios que no reciben remuneracioacuten no esteacuten cubiertos Los empleados del rubro mariacutetimo

y los empleados federales estaacuten cubiertos por leyes similares En caso de tener alguna pregunta

sobre la cobertura consultar con el empleador

QUEacute SE CUBRECasi cualquier lesioacuten o enfermedad recibe cobertura si es como consecuencia del trabajo

Puede ser a causa de un incidente como una caiacuteda exposicioacuten repetitiva o como un

movimiento repetitivo a traveacutes del tiempo Todo estaacute cubierto desde lesiones menores a

accidentes de gravedad La indemnizacioacuten laboral cubre lesiones como consecuencia de

alguacuten delito en el ambiente laboral (Existe la posibilidad de que algunas lesiones derivadas de

actividades voluntarias recreativas fuera del horario laboral actividades sociales o deportivas

por ejemplo el equipo de bolos de la compantildeiacutea ndash no esteacuten cubiertas Consultar con el supervisor

que corresponda o en la Oficina de Reclamos de Indemnizacioacuten Laboral (American Claims

Management Workersrsquo Compensation Office) al 8666715042 en caso de tener preguntas)

La cobertura es automaacutetica e inmediata No hay un plazo para ser aprobado ni es necesario

haber cobrado un salario determinado para recibir la cobertura La proteccioacuten empieza al

momento en el cual se entra al trabajo

COacuteMO REPORTAR UNA LESIOacuteNHay que informar de inmediato al supervisor correspondiente cualquier lesioacuten sin importar

la magnitud Tambieacuten se puede informar de la lesioacuten a ACM por Internet o por teleacutefono al

8666715042

Ademaacutes hay que completar el formulario de reclamos que exige el Estado (DWC 1) y enviarlo al

supervisor o a ACM En caso de necesitar este formulario (DWC 1) las copias estaacuten disponibles

en el sitio WEB de ACM ACMclaimscom debajo de ldquoFormsrdquo

La legislacioacuten del Estado requiere que los empleadores autoricen atencioacuten meacutedica el diacutea laboral

despueacutes de haber recibido el formulario de reclamo los empleadores podriacutean ser responsables

de pagar hasta $10000 por tratamiento hasta que el reclamo se acepte o rechace

COacuteMO RECIBIR ATENCIOacuteN MEacuteDICA Primeros Auxilios Solicitar primeros auxilios de inmediato ya sea en el lugar de trabajo o en el

establecimiento meacutedico que se asigne

Atencioacuten de Emergencia Solicitar atencioacuten meacutedica de inmediato Consultar los nuacutemeros

telefoacutenicos de emergencia publicados en el lugar de trabajo

Nuacutemero Telefoacutenico de Emergencia Llamar al 911 para pedir asistencia de una ambulancia de

los bomberos de la policiacutea o de emergencia por parte de un doctor o de un hospital o dirigirse

a la sala de emergencia maacutes cercana

Consultas por Estado Agudo o de Control En caso de haber designado a su meacutedico personal

con anticipacioacuten comuniacutequese lo antes posible y haga los traacutemites para el tratamiento O

en caso de no haber designado a su meacutedico personal llamar a ACM al 8666715042 cuanto

antes para colaborar con los traacutemites del tratamiento La legislacioacuten del Estado requiere que los

empleadores autoricen el tratamiento meacutedico el diacutea laboral despueacutes de recibir el Formulario de

Reclamo completo Si se demora el reporte de la lesioacuten o la entrega del Formulario de Reclamo

podriacutean demorarse los beneficios y la tardanza excesiva podriacutea poner en peligro el derecho del

empleado a recibir beneficios

INFORMACIOacuteN ADICIONAL SOBRE LA ATENCIOacuteN MEacuteDICAEl tratamiento meacutedico de calidad es la forma maacutes raacutepida de recuperacioacuten

Meacutedico de Cabecera (PTP) El doctor que tiene la responsabilidad general del tratamiento

es el meacutedico de cabecera (PTP) El PTP decide queacute tipo de atencioacuten meacutedica se necesita y

el momento en el cual el empleado puede volver al trabajo Si es necesario el PTP revisa la

descripcioacuten laboral y define cualquier limitacioacuten o restriccioacuten que el empleado pudiera tener al

momento de volver al trabajo El PTP coordina la atencioacuten que el empleado reciba por parte

de otros meacutedicos y en caso de una lesioacuten grave es el que escribe informes sobre cualquier

discapacidad permanente o necesidad de atencioacuten meacutedica en el futuro Uacutenica Oportunidad de Cambiar el PTP El empleado tiene derecho a cambiar el PTP una vez Este

cambio se puede solicitar en cualquier momento

Cambio de PTP Primeros 30 Diacuteas En caso de solicitar el cambio de PTP durante los primeros 30

diacuteas despueacutes de reportar una lesioacuten se puede cambiar el quiropraacutectico personal o acupunturista

en caso de tener un meacutedico designado con anterioridad Cambio de PTP Despueacutes de 30 Diacuteas En caso de no haber usado el cambio de PTP entonces treinta (30) diacuteas despueacutes de reportar

la lesioacuten se puede hacer el cambio de PTP al que el empleado haya elegido Eacuteste puede ser el

meacutedico personal u osteoacutepata el quiropraacutectico acupunturista personal o meacutedico de preferencia

dentro de un aacuterea geograacutefica razonable

Meacutedico Personal (MD o DO) En caso de tener un meacutedico personal que sea (ldquoMDrdquo) u osteoacutepata

(ldquoDOrdquo) y el empleado quiera designar a dicho meacutedico como el PTP el empleado tendraacute que

hacerlo por escrito antes de que ocurra la lesioacuten El meacutedico tiene que estar de acuerdo en

atender al empleado por una lesioacuten o enfermedad de trabajo antes de que la misma suceda

El contenido de este folleto estaacute aprobado por el Director Administrativo de la Divisioacuten de Indemnizacioacuten por Accidentes de Trabajo

FORMULARIOS OPTATIVOSDESIGNACIOacuteN PREVIA DEL MEacuteDICO PERSONAL En caso de que el empleado tenga una lesioacuten o enfermedad relacionada con el trabajo el empleado puede recibir atencioacuten por dicha lesioacuten o enfermedad por parte del meacutedico personal (MD) especialista en medicina osteoacutepata (DO) o grupo meacutedico sibull el empleador ofrece cobertura meacutedica grupalbull dicho meacutedico es el que brinda atencioacuten habitual que se limite a ejercer medicina general o que esteacute habilitado por la junta o internista elegible por la junta pediatra ginecoacutelogo obstetra o cliacutenico y que haya ordenado previamente el tratamiento meacutedico del empleado y que guarde todos los documentos meacutedicosbull el ldquomeacutedico personalrdquo del empleado puede ser un grupo meacutedico si es una sociedad corporativa uacutenica compuesta por doctores en medicina habilitados u osteoacutepatas que operen como un grupo meacutedico integral con especialidades muacuteltiples que brinden atencioacuten principalmente por enfermedades o lesiones que no sean de trabajobull antes de la lesioacuten el meacutedico debe estar de acuerdo en atender al empleado por lesiones o enfermedades laboralesbull antes de la lesioacuten el empleado debe presentar al empleador lo siguiente por escrito (1) una nota que diga que el empleado quiere que el meacutedico personal lo atienda por alguna lesioacuten o enfermedad laboral y (2) el nombre y la direccioacuten comercial de eacutesteEste formulario se puede utilizar para notificar al empleador en caso de que el empleado desee que el meacutedico personal o doctor osteoacutepata lo atienda por alguna lesioacuten o enfermedad laboral y si se cumplen los requisitos mencionados arriba

NOTIFICACIOacuteN DE DESIGNACIOacuteN PREVIA DEL MEacuteDICO PERSONALEmpleado Completar esta seccioacuten

Para (nombre del empleador)

En caso de tener una lesioacuten o enfermedad laboral elijo que me atienda

Nombre del doctor

Calle Ciudad Estado y Coacutedigo Postal

Teleacutefono

Nombre del Empleado

Direccioacuten del Empleado

Firma del Empleado

Fecha

(Meacutedico o Designacioacuten del Empleado del Meacutedico o Grupo Meacutedico)El meacutedico no tiene obligacioacuten de firmar este formulario sin embargo si el meacutedico o el empleado del meacutedico o grupo meacutedico no firma se necesitaraacute otra documentacioacuten como comprobante de que el meacutedico estaacute de acuerdo en la designacioacuten previa seguacuten el Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 9780 1(a)(3)

Tiacutetulo 8 Coacutedigo de Reglamento de California seccioacuten 9783 DWC Formulario 9783 (1 de marzo de 2007)

Nota para el Empleado A menos que un empleado esteacute de acuerdo ni el empleador ni el ACM se comunicaraacuten con su meacutedico personal para confirmar una designacioacuten previa [CCR 97801(f)] Si su meacutedico no firma el formulario anterior se requeriraacute otra documentacioacuten de su designacioacuten previa antes de que se sufra una lesioacuten Si usted estaacute de acuerdo despueacutes de recibir este formulario que su empleador o ACM pueden comunicarse con su meacutedico para confirmar la designacioacuten previa por favor firme abajo

Firma del Empleado

Nordm de Identificacioacuten del Empleado

Fecha

Note to Physician Los servicios meacutedicos de indemnizacioacuten del trabajador estaacuten sujetos a autorizacioacuten previa de servicios que no sean de emergencia revisioacuten de utilizacioacuten requisitos de presentacioacuten de informes y la Lista Oficial de Honorarios Meacutedicos de California La siguiente informacioacuten opcional puede ayudar a la comunicacioacuten y facilitar el proceso de autorizacioacuten generacioacuten de informes registros y pagos

Gerente de Oficina Contacto de Facturacioacuten

Nuacutemero telefoacutenico

Direccioacuten Postal (si es diferente al domicilio)

Fax

Correo electroacutenico

Licencia Meacutedica nordm

Identificacioacuten Tributaria nordm

Red de Profesionales Meacutedicos (MPN) Debido a que es el empleador el que ofrece la MPN el meacutedico de la red es el que en general va a ser el PTP mientras dure el tratamiento si bien se puede efectuar el cambio a otro meacutedico de la red en cualquier momento antes o despueacutes de la consulta En caso de querer hacer el cambio a un quiropraacutectico o acupunturista incluyendo un quiropraacutectico personal o acupunturista personal antes de la lesioacuten el profesional tiene que estar en la red El empleador o el ACM pueden brindar informacioacuten adicional con respecto a la

red y los derechos del empleado seguacuten el plan

BENEFICIOSAtencioacuten Meacutedica ACM paga directamente los gastos meacutedicos por tratamiento razonable y necesario en nombre del empleador El empleado jamaacutes debe recibir las facturas meacutedicas por atencioacuten autorizada ni efectuar el pago de las mismas Todas las facturas se enviacutean a American Claims Management a PO Box 85251 San Diego CA 92186 Existe un limite en algunos de los servicios medicosDiscapacidad Temporal En caso de que el empleado no esteacute en condiciones de trabajar por maacutes de tres diacuteas incluyendo los fines de semana tiene derecho a recibir pagos por discapacidad temporal (TD) como reemplazo del salario que no pudo recibir Dos semanas despueacutes del reporte de la lesioacuten el empleado recibiraacute un cheque de ACM Este cheque continuaraacute llegando cada dos semanas hasta que los meacutedicos digan que el empleado estaacute en condiciones de volver al trabajo o hasta que digan que el cuadro meacutedico es ldquopermanente y estacionariordquo (Los pagos no se efectuacutean durante los tres primeros diacuteas salvo sin embargo que el empleado esteacute internado en un hospital o no esteacute en condiciones de trabajar por maacutes de 14 diacuteas) El monto de estos cheques es de dos-tercios del salario promedio del empleado supeditado a los miacutenimos y maacuteximos establecidos por la legislacioacuten del Estado No hay deducciones y los pagos son libres de impuestos Seguacuten la legislacioacuten de California los pagos por TD por una uacutenica lesioacuten no deben exten-derse por maacutes de 104 semanas remunerables en el transcurso de cinco antildeos a partir de la fecha de la lesioacuten o por maacutes de 240 semanas en el transcurso de cinco antildeos a partir de la fecha de la lesioacuten para determinadas lesiones a largo plazo tales como quemaduras de gravedad o enfermedad pulmonar croacutenica Si se llega al periacuteodo maacuteximo del pago de la TD antes de poder volver al trabajo o antes de que el cuadro meacutedico sea permanente y estacionario el empleado puede recibir beneficios de discapacidad por medio del Departamento de Desarrollo Laboral de California (EDD) Es posible que el empleado tambieacuten pueda recibir estos beneficios si el pago por TD se niega o se demora Discapacidad Permanente Si el meacutedico dice que la lesioacuten o enfermedad tiene como consecuencia limitaciones o restricciones permanentes en la capacidad laboral del empleado el empleado podriacutea tener la posibilidad de recibir pagos por discapacidad permanente El monto depende del informe del doctor de cuaacutento de dicha discapacidad permanente haya sido causa directa del trabajo y demaacutes factores como edad ocupacioacuten tipo de lesioacuten y fecha de la lesioacuten El pago del beneficio tambieacuten se puede ver afectado por el hecho de que si el empleador hizo o no una oferta adecuada para volver al trabajo y si el empleado la aceptoacute o no Los montos miacutenimos y maacuteximos estaacuten determinados por la legislacioacuten del Estado pero si el empleado tiene una discapacidad permanente ACM enviaraacute una carta con la explicacioacuten de coacutemo se calculoacute el beneficio En general el monto total se establece de acuerdo con una tasa semanal distribuida sobre una cantidad determinada de semanas El plazo del primer pago se vence a los 14 diacuteas despueacutes del pago final por discapacidad o en caso de que el empleado no estuviera recibiendo pagos temporales por discapacidad 14 diacuteas despueacutes de que el doctor diga que el estado es permanente y estacionario Despueacutes de eso el beneficio se pagaraacute cada

14 diacuteas hasta que el empleado reciba el maacuteximo hasta que se resuelva el caso o reciba una cantidad total como pago Beneficios por Fallecimiento Si la lesioacuten o enfermedad es la causa del fallecimiento los pagos se efectuaraacuten a las personas que dependiacutean econoacutemicamente del empleado Estos beneficios estaacuten establecidos en la legislacioacuten del Estado y el monto depende de la cantidad de dependientes y de la fecha de la lesioacuten La indemnizacioacuten laboral tambieacuten brinda aportes para el funeral Beneficio Suplementario por Desplazamiento Laboral Una vez que ACM recibe un informe meacutedico de que usted se ha recuperado lo maacutes posible de su lesioacuten ocupacional y su lesioacuten resulta en discapacidad permanente en un periodo no mayor de 60 diacuteas ACM enviaraacute una carta informaacutendole si su empleador tiene una labor modificada o trabajo alternativo disponible para usted Si su empleador no le ofrece trabajo modificado o alternativo ACM tiene 20 diacuteas para ofrecerle el Beneficio Complementario de Desplazamiento Laboral Se trata de un bono no transferible de $ 6000 que se debe utilizar en una escuela acreditada del Estado para recibir recapacitacioacuten relacionada con la educacioacuten o perfeccionamiento profesional Hay liacutemites de cuaacutento usted puede gastar en algunas cosas pero si usted reuacutene los requisitos obtendraacute informacioacuten sobre queacute tipos de gastos estaacuten cubiertos los liacutemites requisitos de documentacioacuten y plazos para el uso de este beneficio Other Benefits Para aclarar el seguro de Indemnizacioacuten del Trabajador cubre lesiones y enfermedades ocurridas en el lugar de trabajo y es pagado en su totalidad por su empleador mientras que el Seguro de Discapacidad del Estado (SDI) cubre lesiones o enfermedades ocurridas fuera del trabajo y es pagado mediante deducciones de su cheque de pago Si usted no estaacute recibiendo beneficios de indemnizacioacuten del trabajador usted puede ser elegible para recibir beneficios del SDI Para obtener maacutes informacioacuten llame a la oficina estatal local de Desarrollo de Discapacidad de Empleo que figura en las paacuteginas del gobierno de su guiacutea telefoacutenica o visite wwwEDDcagovdisability Si el estado determina que el monto por discapacidad permanente con derecho a indemnizacioacuten del trabajador es muy bajo en comparacioacuten con la peacuterdida de ganancias futuras usted puede calificar para recibir dinero adicional de un Fondo de Retorno al Trabajo aprobado por los legisladores del estado en 2012 Este fondo es administrado por el Departamento de Relaciones Industriales se incluiraacuten detalles sobre la elegibilidad y coacutemo solicitarlo en las normas estatales Si usted cree que reuacutene los requisitos comuniacutequese con la oficina local de Informacioacuten y Asistencia de DWC que aparece en su centro de trabajo o puede llamar al 8007367401 o visitar el sitio Web de la Divisioacuten de Indemnizacioacuten del Trabajador wwwDWCcagov

iquestPREGUNTASPara cualquier pregunta dirigirse al supervisor que corresponda o a ACM La direccioacuten y el nuacutemero de teleacutefono de ACM aparecen al final de este documento Tambieacuten se puede comunicar con el personal de informacioacuten y asistencia de la Divisioacuten de Indemnizacioacuten Laboral del Estado (DWC) El personal de informacioacuten y asistencia estaacute a disposicioacuten sin costo alguno para contestar cualquier pregunta consulta de problemas y para brindar por escrito informacioacuten adicional sobre indemnizacioacuten laboral La oficina local aparece al final de este documento y estaacute publicada en su lugar de trabajo o puede llamar al 8007367401 consultar las paacuteginas blancas de las guiacuteas telefoacutenicas locales bajo Oficinas del Gobierno EstatalRelaciones IndustrialesIndemnizacioacuten Laboral o visitar el sitio web de DWC en wwwdircagovdwc

EL FRAUDE PARA RECIBIR INDEMNIZACIOacuteN POR ACCIDENTE DE TRABAJO ES UN DELITO

Toda persona que presente o sea la causa de que se presenten declaraciones fal-sas o fraudulentas con el fin de recibir o negar beneficios o indemnizacioacuten laboral es culpable de un delito

Reclamos Administrados por American Claims ManagementPO Box 85251San Diego CA 92186

Liacutenea Telefoacutenica Gratuita 8666715042ACMclaimscom

NO DISCRIMINACIOacuteN Es iliacutecito que el empleador despida o efectuacutee alguacuten tipo de discrimi-nacioacuten contra alguacuten empleado como consecuencia de la presentacioacuten de un reclamo de la intencioacuten de presentar un reclamo del recibo de una indemnizacioacuten por declarar o tener la intencioacuten de declarar a favor de otro empleado lesionado Si se determina que el empleador discriminoacute a alguacuten empleado se le podriacutea ordenar al empleador que vuelva a contratar a di-cho empleado que le reembolse el salario que no recibioacute que le otorgue beneficios laborales y que le pague una mayor indemnizacioacuten gastos y costos hasta el maacuteximo que disponga la legislacioacuten del estado

OFICINAS DE INFORMACIOacuteN Y ASISTENCIA

Informacioacuten Acerca de Indemnizacioacuten Laboral

FORMULARIO OPTATIVONOTIFICACIOacuteN DE QUIROPRAacuteCTICO PERSONAL O ACUPUNTURISTA PERSONAL Si el empleador o la compantildeiacutea de seguro del empleador no tiene una Red de Profesionales Meacutedicos es posible que se pueda cobrar al quiropraacutectico o acupunturista personal en vez de al meacutedico de cabecera despueacutes de una lesioacuten o enfermedad de trabajo Para poder hacer este cambio el empleado tiene que darle al empleador el nombre y la direccioacuten del quiropraacutectico o acupunturista personal por escrito antes de la lesioacuten o enfermedad En general el administrador de reclamos tiene derecho a seleccionar al meacutedico de cabecera dentro de un plazo de 30 diacuteas despueacutes de que el empleador tenga conocimiento de la lesioacuten o enfermedad Despueacutes de que el administrador de reclamos haya iniciado el tratamiento con otro meacutedico durante este periacuteodo entonces el empleado puede a pedido solicitar que el tratamiento se transfiera al quiropraacutectico o acupunturista personal Este formulario se puede utilizar para entregar al empleador la informacioacuten del quiropraacutectico o acupunturista personal

Nombre del quiropraacutectico o acupunturista (DC LAc)

Calle Ciudad Estado Coacutedigo Postal

Teleacutefono

Nombre del Empleado (en letra de bloque)


Firma del Empleado

Fecha


Nota para el Empleado La ley estatal no permite que un quiropraacutectico sea un meacutedico tratante maacutes allaacute de un maacuteximo de 24 visitas El quiropraacutectico personal debe ser el quiropraacutectico habitual y habilitado (DC) que haya ordenado un tratamiento previo y que tenga los documentos pertinentes incluyendo la historia del tratamiento quiropraacutectico El acupunturista debe ser un acupunturista habitual y habilitado (LAc) que haya ordenado un tratamiento previo y que tenga los documentos pertinentes incluyendo la historia del tratamiento de acupunturaSi el empleador ofrece una Red de Profesionales Meacutedicos para Accidentes de Trabajo (MPN) el empleado podraacute uacutenicamente cambiar a un quiropraacutectico o acupunturista personal dentro de la red de MNP En caso de que el empleado sea miembro de la Organizacioacuten de Atencioacuten de la Salud por Accidentes de Trabajo (HCO) rigen normas diferentes por este motivo consultar con el empleador o administrador de reclamos si ese es el caso

simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367

California law guarantees certain benefits to employees who are injured or become ill because of their jobsWorkers compensation covers any job-related injury - even first-aid type injuries and work-related illnesses including physicalor psychiatric injuries resulting from a workplace crime It can be caused by one event such as a fall or repeated exposuressuch as doing a repetitive motion over timeThe key is whether it was caused by the job (Some injuries from voluntary off-dutyrecreationalsocial or athletic activity- for examplethe company bowling team- may not be covered Check with yoursupervisor or the claims administrator listed below if you have questions)Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illnessso you should never see a bill Medical benefits may include treatment by a doctor hospital services lab tests x-rays physicaltherapy and medicines but there are limits on some medical servicesPayment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illnessyouwill receive temporary disability payments Temporary disability payments may change or stop when your doctor says you areable to return to work or that your medical condition is permanent and stationary For most injuries state law limits temporarydisability payments to a maximum of 104 weeks within five years of the date of injury These benefits are tax free Temporarydisability payments are two-thirds of your average weekly pay subject to minimums and maximums set by state law Paymentsare not made for the first three days unless you are hospitalized or cannot work for more than 14 days If Temporary Disabilitybenefits have been delayed denied or terminated you may be eligible for State Disability benefits To learn more call 800-480-3287 orvisit their website at wwwEDDcagovdisabilityPayment for Permanent Disability If your injury or illness results in a permanent disability you may receive additionalpayments The amount will be based on the portion of your permanent disability that is directly attributable to your work andwill also depend on the type of injury your age occupation and date of injury If your employer has 50 or more employees andyou were injured before 2013 the amount also may be affected by whether or not your employer makes a suitable return-to-work offerSupplemental Job Displacement Benefit Once a doctorrsquos report indicates that you have recovered as much as you aregoing to and that you have a permanent disability within 60 days you may receive a form with an offer of regular modified oralternative work from your employer If 60 days from receipt of your doctorrsquos report there is no offer made for regular modifiedor alternative work the administrator has 20 days to offer you a Supplemental Job Displacement Benefit or otherwise knownas a lsquovoucherrsquo for up to $6000 that you can use for retraining or skill enhancement at a state-approved school or to help pay forother resources that can help you find a new job If you qualify your claims administrator will pay the costs up to the maximumset by state law (Note for pre-2013 injuries you may qualify for a voucher if your injury results in a permanent disability thatprevents you from returning to work within 60 days after your temporary disability ends and your employer doesnrsquot offer youappropriate modified or alternative work The amount of the voucher for a pre-2013 injury ranges from a minimum of $4000 toa maximum of $10000 depending upon your level of permanent disability)Death Benefits If the injury or illness causes death payments may be made to individuals who were financially dependent onthe worker Workers compensation also pays a burial allowanceReturn to Work Supplement If your work injury results in a permanent disability and the state determines that your workerscompensation permanent disability benefit is too low compared to your loss of future earnings you may qualify for additionalmoney from the Return-to-Work Fund approved by state lawmakers in 2012 This fund will be administered by the Departmentof Industrial Relations and details on eligibility and how to apply will be included in state regulations so if you have questionsor think you may qualify contact the local DWC Information and Assistance office listed below or check the Division of WorkersCompensation web site at wwwdwccagov for information1 For an ambulance hospital the fire department or the police cal 911 For non-emergency medical care refer to the medicalcontact information below otherwise seek first aid from your employerDoctorClinic__________________________________________________ Telephone________________________________________Address________________________________________________________________________________________________________2 Report all injuries IMMEDIATELY to your supervisor or employer representative at _______________(phone number) Youremployer is required to provide you with a claim form within one working day of learning of your injury so insure your right tobenefits by reporting every injury no matter how slight and request a claim form if its more than a simple first-aid injury Thereare time limits for notifying your employer about a work injury so dont delay as waiting to report may delay workerscompensation benefits and you may not be able to get benefits if you dont file a claim within one year of the date of injury thedate you knew the injury was work related or the date benefits were last provided Your employer must notify the claimsadministrator and authorize medical care consistent with applicable treatment guidelines within one working day of receiving acompleted claim form and will direct you to a doctor or clinic if necessary Until a claim is accepted or denied employers maybe liable for as much as $10000 in treatment If your claim or benefits are denied you have a right to challenge the decision atthe Workers Compensation Appeals Board but there are deadlines for filing the papers so dont delay3 See your Primary Treating Physician (PTP)This is the doctor with overall responsibility for treating your injury or illness Youcan be treated immediately by a predesignated personal doctor (medical doctordoctor of osteopathic medicineor mufti-specialty medical group) who has treated you in the past and has your medical records if 1) you have health care coverage fornonwork injuries and illnesses 2) prior to the injury or illness your doctor agreed to treat you for work injuries and illnessesand3) you gave your employer the doctors name and address in writing before the injury or illness Otherwise your employer hasthe right to select the physician who will treat you for the first 30 days and the claims administrator will arrange your medicaltreatment often by a specialist for the particular injury Different rules regarding your medical care apply if you gave your employerthe name of a personal doctor who is a chiropractor or acupuncturistor if your employer is using a Health CareOrganization(HCO) or a workers compensation Medical Provider Network (MPN - see below) so check with your claimsadministrator in those situations4 Notify your claims administrator if you want to switch doctors If you did not predesignate a personal physician and youremployer does not use an HCO or an MPN you can switch to a doctor of your choice 30 days after the injury is reported or ifyou want to change doctors before then your claims administrator will give you a list of doctors to choose from If you arecovered by an HCO or an MPN your employer should provide you with information on those plans including how to switchdoctors5 See your employer representative or claims administrator if you have questions It is illegal for an employer to fire ordiscriminate against you just because you file intend to file or settle a workers compensation claim or because you testify fora co-worker who was injured If you prove this kind of discrimination you may receive job reinstatement lost wages andincreased benefits plus costs and expenses up to limits set by the stateAn MPN is a network of health care providers who treat workers injured on the job If your employer is using an MPN and youhave a predesignated personal physician you may receive treatment from that doctor If you do not have a predesignatedpersonal physician and your employer has an MPN you may switch to an appropriate provider from the MPN list after the firstmedical visit directed by your employer If you are receiving treatment for an existing injury from a doctor who is not in the MPNyou may be required to change to a doctor within the MPN If your employer has an MPN you can use the contact informationbelow to get more informationCurrent MPNs toll-free number______________________MPN Website_________________________________________________MPN Effective date______________________Current MPNs address___________________________________________________Name________________________________________________________________________ Check if employer is self-insuredTelephone Number_________________________________________ _______Policy Expiration Date________________________If no claims administrator is listed above and the employer is not self-insured you may be able to find the name of the employersworkers compensation insurer at wwwcaworkcompcoveragecom If the workers compensation policy has expired contactthe Division of Labor Standards Enforcement (DLSE) Look in your phone book under State GovernmentIndustrialRelationsLabor Standards Enforcement or learn more at wwwdircagovdlseYou can also get free information from a State Division of Workers Compensation Information and AssistanceOfficer hear recorded information and get a list of local offices by calling (800) 736-7401 or learn more atwwwdwccagov The nearest Information and Assistance Officer is located atStreet Address__________________________________________________________ Telephone_______________________________

WORKERS COMPENSATION FRAUD IS A FELONYAnyone who makes or causes to be made any knowingly false or fraudulent material statement or material representation forthe purpose of obtaining or denying workers compensation benefits or payments IS guilty of a felony and may be fined andimprisoned

WarningThis notice has been approved by the Administrative Director of the Division of Workersrsquo Compensation

All rights reserved Rev 113

If A Work InjuryOccurs

BenefitsInclude

In The Event OfA Work Injury

ClaimsAdministrator

Medical ProviderNetworks

866-671-5042

AMERICAN CLAIMS MANAGEMENT INC

PO BOX 85251 SAN DIEGO CA 92186

866-671-5042 FAX 619-744-5030

La ley de California garantiza determinados beneficios para los empleados que se lastiman o se enferman a causa de su trabajoLa compensacioacuten al trabajador cubre cualquier lesioacuten relacionada al trabajo aun el tipo que soacutelo requiere primeros auxilios asiacute como lasenfermedades relacionadas con el trabajo inclusive lesiones fiacutesicas o psiquiaacutetricas que resultan de un crimen en la faacutebrica Esta puede sercausada por un evento tal como una caiacuteda o exposiciones repetidas tal como hacer un movimiento repetitivo a traveacutes del tiempo Laclave es si la lesioacuten o enfermedad ha sido causada por el trabajo o no (Algunas lesiones causada por actividades voluntarias fuera deltrabajo sociales o de atletismo por ejemplo el equipo de bolos de la compantildeiacutea posiblemente no esteacuten cubiertas si tiene algunapregunta consulte con su supervisor o con el administrador de reclamos cuyo nombre aparece maacutes abajo)Atencioacuten meacutedica Su administrador de reclamos pagaraacute todo cuidado meacutedico razonable y necesario meacutedico de su lesioacuten o enfermedadde trabajo asiacute es que usted nunca deberiacutea ver una cuenta Los beneficios meacutedicos pueden incluir el tratamiento por un doctor serviciosdel hospital pruebas de laboratorio radiografias terapia fisica y medicinas pero hay liacutemites en algunos servicios meacutedicosPago para peacuterdida de salario Si usted no puede trabajar mientras usted se recupera de una lesioacuten o enfermedad en el trabajousted recibiraacute pagos temporarios de iacutencapaciacutedad Los pagos por incapacidad temporal pueden cambiar o pueden parar cuando sudoctor dice que usted puede volver a trabajar o que su condicioacuten meacutedica es permanente y estacionariacutea Para la mayoriacutea de lesionesla estatal soacutelo permite incapacidad temporal a los pagos realizados por un maacuteximo de 104 semanas dentro de cinco antildeos desde lafecha de la Estos beneficios son libres de impuestos Los pagos temporarios de incapacidad son dos tercios de su promedio de pagasemanal sujetos a miacutenimos y maacuteximos fijados por ley estatal Los pagos no se efectuacutean para los primeros tres diacuteas amenos queusted esteacute internado en un hospital o incapacitado para trabajar durante maacutes de 14 diacuteas Si los beneficios por Incapacidad Temporal sehan demorado denegado o cancelado usted puede ser elegible para beneficios de Incapacidad del Estado Para obtener maacutes informacioacutenllame al 800-480-3287 o visite su sitio web en wwwEDDcagovdisabilityPago para una incapacidad permanente Si la lesioacuten o enfermedad resulta en una incapacidad permanente usted puede recibirpagos adicionales La cantidad se basaraacute en la porcioacuten de su incapacidad permanente que es directamente atribuible a su trabajo ytambieacuten depende del tipo de lesioacuten de su edad de su ocupacioacuten y de la fecha de la lesioacuten Si su empleador tiene 50 o maacutes empleados yusted se lesionoacute antes de 2013 su pago de beneficio tambieacuten puede ser afectada por el hecho de que su empleador le haga o no unaoferta de regresar a trabajarBeneficio suplementario de desplazo de empleo Una vez que el informe meacutedico indique que usted se ha recuperado tanto comosea posible y que usted tiene una discapacidad permanente dentro de los siguientes 60 diacuteas usted recibiraacute un formulario con una ofertade empleo regular modificado o alternativo por parte de su empleador Si despueacutes de 60 diacuteas a partir de la fecha en que recibioacute el informemeacutedico no le han hecho una oferta de empleo regular modificado o alternativo el administrador tiene 20 diacuteas para ofrecerle un BeneficioSuplementario por Destitucioacuten del Empleo tambieacuten conocido como un lsquovalersquo por hasta $6000 que usted puede usar para capacitarse omejorar sus habilidades en una escuela aprobada por el estado o para ayudar a pagar por otros recursos que le pueden ayudar a encontrarun empleo nuevo Si usted califica su administrador de reclamos pagaraacute los costos hasta el maacuteximo fijado por la ley estatal (Nota paralesiones anteriores al 2013 usted puede calificar para un vale si su lesioacuten resulta en una discapacidad permanente que evite que ustedregrese a trabajar dentro de los siguientes 60 diacuteas despueacutes de que su discapacidad temporal termine y su empleador no le haga elofrecimiento de empleo modificado o alterno apropiado La cantidad del vale para una lesioacuten anterior al 2013 estaacute en el rango de unmiacutenimo de $4000 a un maacuteximo de $10000 dependiendo de su nivel de discapacidad permanente)Beneficios si la lesioacuten resulta en muerte Si la lesioacuten o enfermedad le causa la muerte los pagos se le pueden hacer a las personasque dependiacutean financieramente del trabajador La compensacioacuten de trabajadores tambieacuten proporciona una concesioacuten de entierroSuplemento para Regresar al Trabajo Si su lesioacuten de trabajo resulta en una discapacidad permanente y el estado determina quesus beneficios por discapacidad por compensacioacuten al trabajador es demasiado bajo comparado con su peacuterdida de ingresos futuros ustedpuede calificar para obtener dinero adicional del lsquoFondo de Regreso al Trabajorsquo aprobado por los legisladores del estado en el 2012 Estefondo seraacute administrado por el Departamento de Relaciones Industriales y los detalles sobre la elegibilidad y coacutemo solicitarlo estaraacutenincluidos en las regulaciones estatales por lo que si usted tiene preguntas o cree que califica contacte a la oficina local de Informacioacuten yAsistencia de DWC enlistada debajo o revise el sitio web de la Divisioacuten de Compensacioacuten al Trabajador Lesionado en wwwdwccagov1 Para una ambulanciahospital los bomberos o la policiacutea llame al 911 Si necesita atencioacuten meacutedica pero no es una emergenciaconsulte la informacioacuten de contacto meacutedicos listados abajo de lo contrario busque primeros auxilios de su empleadorDoctorClinica__________________________________________________ Nuacutemero de teleacutefono_____________________________________Direccioacuten_____________________________________________________________________________________________________________2 Reporte todas las lesiones inmediatamente a su supervisor o representante del empleador a _______________(nuacutemero de teleacutefono )A su empleador se le requiere proporcionarle un formulario de reclamacioacuten a maacutes tardar un diacutea laborable despueacutes de saber de su lesioacutenasiacute es que asegure su derecho a beneficios informando cada lesioacuten por leve que sea y solicite un formulario de reclamo si es maacutes que unalesioacuten sencilla de primeros auxiliosExisten plazo s para notificar a su empleador acerca de un accidente de trabajo asiacute que no demora porque esperar que informe a suempleador puede retrasar los beneficios de compensacioacuten para trabajador es y es posible que usted no pueda obtener beneficios si ustedno archiva un reclamo dentro de un antildeo de la fecha en que usted supo que la lesioacuten estaba relacionada con el trabajo o la fecha en quelos beneficios se le propo rcionaron la uacuteltima vezSu empleador debe notificar al administrador de reclamos y debe autorizar el tratamiento meacutedico consistente con las pautas detratamiento a maacutes ta rdar un diacutea haacutebil despueacutes de recibir el formulario de reclamo y se le dirigiraacute a un meacutedico o cliacutenica si es necesarioHasta que un reclamo se acepte o se recha ce los emplead ores puede n ser respo nsables hasta por $10000 en tratamiento Si sureclamo o beneficios se le niegan usted tiene el derecho de impugnar la decisioacuten con la Junta de Apelaciones para compensacioacuten de lostrabajadores pero existen plazos para archivar los papeles asiacute es que no se demore3 Consulte al Meacutedico que le esta Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o enfermedadPuede recibir tratamiento inmediato de parte de un meacutedico person al predesignado (Doctor de Medicina Doctor de Osteopatia o ungrupo de muacuteltiples especialidades medicas) pero un meacutedico personal predesrqnadc debe haber tratadose en el pasado y tener su historialmeacutedico Puede solamente tener un proveedore meacutedico predesignado si 1) usted tiene cobertura de atencioacuten meacutedica para las lesiones nolaborales y enfermedade s 2) antes que usted se lesionara su meacutedico acordoacute tratarlo por sus lesiones y padecimientos de trabajo y 3)usted le dio a su empleador el nombre y el domicilio del meacutedico por escrito antes de la lesioacuten De lo contrario su empleador tiene elderecho de seleccionar al meacutedico que le proporcionaraacute a su tratamiento meacutedico para los primeros 30 diacuteas y el administrador de reclamosharaacute los arreglos necesar ios para el t ratamiento meacutedico con frecuencia con un especialista que trata la lesioacuten en particular Aplicandiferentes reglas con respecto a su atencioacuten meacutedica si usted le proporcionoacute a su empleador el nombre de un meacutedico personal que seaquiropraacutectico o acupunturista o si su empleador estaacute usando una Organizacioacuten de Cuidado de la Salud (HCO por sus siglas en ingleacutes) ouna Red de Proveedores Meacutedicos de Compensacioacuten al Trabajador Lesionado (MPN por sus siglas en ingleacutes ndash vea debajo) asiacute queaseguacuterese de revisar con su administrador en aquellas situaciones4 Siempre notifique a su administrador de reclamos si desea cambiar de meacutedico Si usted no ha predesignado un meacutedico personal antesde lesioacuten y su empleador no usa una MPN o una HCO usted puede cambiar a su propio doctor 30 diacuteas despueacutes de que la lesioacuten sereporte o si usied quiere cambiar doctores antes de eso su administrador de reclamos le daraacute una lista de doctores de los cuales escogerSi usted estaacute cubierto por una HCO o una MPN su empleador debe proporcionarle informacioacuten sobre estos planes incluyendo la manerade cambiar de meacutedico5 Consulte al representante del empleador o al administrador de reclamos si tiene preguntas Es ilegal que un empleador lo despida odiscrimine contra usted solamente porque usted archive piense archivar o llegue a un acuerdo de un reclamo de compensacioacuten altrabajador o porque usted testifique a favor de un compantildeero de trabajo que fue lesionado Si usted prueba esta clase de discriminacioacuten usted tendraacute derecho a ser reinstaurado los sueldos perdidos y beneficios aumentados maacutes costos y gastos hasta el maacuteximo fijado por elestado Una MPN es una red de proveedores de asistencia meacutedica seleccionados para dar tratamiento a los trabajado res lesionados enl eltrabajo Si su empleador usa una MPN y usted tiene un meacutedico personal predesignado usted puede recibir tratamiento de ese doctor Siusted no tiene un meacutedico personal predesignado y su empleador usa una MPN usted puede cambiar a un proveedor apropiado de la listade proveedores de la MPN despueacutes de la primera visita meacutedica dirigida por su empleador Si usted estaacute recibiendo tratamiento de parte deun meacutedico que no pertenece a la MPN para una lesioacuten existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Sisu empleador usa una MPN usted puede usar la informacioacuten de contacto que se indica abajo para obtener maacutes informacioacuten

Nuacutemero gratuito de la MPN_______________________________________ Paacutegina web de la MPN_______________________________________

Fecha de vigencia de la_____________________________ Direccioacuten de la MPN vigente_______________________________________________

Nombre_______________________________________________________________________ Marque aquiacute si la compantildeia tiene su propiacuteo seguroNuacutemero de teleacutefono__________________________________________________Fecha de vencimiento de la poacuteliza__________________________Si la informacioacuten sobre el administrador de reclamos no aparece arriba y siacute la empresa no cuenta con su propio seguro tal vez sea posibleencontrar el nombre de la aseguradora de compensacioacuten trabajadores de su empleador en wwwcaworkcompcoveragecom Siacute la poacutelizade compensacioacuten al trabajador ha vencido comuniquese con Divisioacuten para el Cumplimiento de las Normas Laborales (Division al LaborStandards Enforcement DLSE) Busque en el directorio telefoacutenico bajo State Govemmentllndustrial RelationsLabor Standards Enforcemento aprenda maacutes en wwwdlrcagovdlseUsted tambieacuten puede obtener informacioacuten gratuita de un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten deTrabajadores escuchar informacioacuten grabada y obtener una lista de oficinas locales llamando al (800) 736-7401 o aprenda maacutes enwwwdwccagov El oficial de informacioacuten y asistencia maacutes cercano se localiza en

Direccioacuten_____________________________________________________________________________ Teleacutefono______________________________

DEFRAUDAR A COMPENSACIOacuteN AL TRABAJADOR ES UN CRIMENCualquier persona que haga o que ocasione que se haga una declaracioacuten o una representacioacuten material intencionalmentefalsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores es culpable de undelito grave y puede ser multado y encarcelado

AdvertenciaEste aviso ha sido aprobado por el Director Administrativo de la Divisioacuten de Compensacioacuten al Trabajador


Si Ocurre UnaLesioacuten En ElTrabajo

BeneficiosIncluyen

En CasoDe UnaLesioacuten EnEl Trabajo

Administradorde Reclamos

Redes deproveedoresmeacutedicos 866-671-5042


AMERICAN CLAIMS MANAGEMENT INC866-671-5042 FAX 619-744-5030

AMERICAN CLAIMS MANAGEMENT INCOffers

TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$

FOR INFORMATION LEADING TO THE ARREST AND CONVICTION OF ANY CO-WORKER HEALTH CARE PROFESSIONAL OR ATTORNEY REPRESENTING A FRAUDULENT WORKERS

COMPENSATION CLAIM TO AMERICAN CLAIMS MANAGEMENT INC

California law makes it a FELONY to make or cause to be made a knowingly false or fraudulent material statement in order to obtain Workers Compensation benefits (Insurance Code Section 18711) American Claims Management Inc believes that any party engaging in such fraud should be prosecuted to the fullest extent of the law including JAIL SENTENCES

Call our TOLL-FREE FRAUD HOTLINE immediately if you have information on a fraudulent claim You and all of us reap the rewards of reducing workers Compensation Fraud

Maximum reward of $1000 per conviction In the event more than one individual submits information regarding the same fraudulent claim American Claims Management Inc will equally divide the reward among those providing information used in obtaining the conviction American Claims Management Inc reserves the right to determine what information if any will be provided to the appropriate law enforcement agency Criminal prosecutions are the sole responsibility of the authorities and may or may not be pursued at their discretion Any issues regarding the interpretation of this policy shall be resolved by American Claims Management Inc at their sole discretion Program subject to change or termination without prior notice

1-866-671-5042American Claims Management Inc

LA COMPANtildeIA DE SEGUROSAMERICAN CLAIMS MANAGEMENT INC

Ofrece

LLAMADA GRATIS

DEMANDASFRAUDULENTAS DECOMPENSACION DE

TRABAJADORES

RECOMPENSA

1000$

Llame gratis por nuestra LINEA DIRECTA PARA REPORTAR FRAUDES inmediatamente si usted tiene informaciones de una demando fraudulenta Usted y todos nosotros obtendremos el beneficio de reducir los fraudes en la compensacioacuten de trabajadores

La recompensa maacutexima es de $1000 por conviccioacuten En caso de que maacutes de una persona presente informaciones sobre la misma demando fraudulenta American Claims Management Inc dividiraacute la recompensa por partes iguales entre aquellas persones que aportaron informaciones para obtener la conviccioacuten American Claims Management Inc se reserva el derecho de determinar queacute informacion presentaraacute a la agencia judicial correspondiente El proceso de criacutemenes es la responsibilidad exclusiva de las autoridades que pueden decidir si el proceso debe entablarse o no Cualquier disputa que pudiera surgir en la interpretacioacuten de esta ofreta seraacute resuelta por a propia Compantildeia de Seguros American Claims Management Inc Este programa estaacute sujeto a cambios a a cancelacioacuten sin aviso previo


POR INFORMACIONES QUE CONDUZCAN AL ARRESTO Y CDNDENA DE CUALQUIER TRABAJADOR PROFESIONAL DE LA SALUD O ABOGADO QUE PRESENTE UNA DEMANDA DE COMPENSACION

FRADULENTA POR ACCIDENTE DEL TRABAJO A LA COMPANtildeIA DE SEGUROS AMERICAN CLAIMS MANAGEMENT INC

Las leyes de California declaran que es un DELITO GRAVE presentar o hacer que se presenten pruebas falsas o declaraciones

fradulentas para obtener beneficios de compensacioacuten pro accidentes del trabajo (Coacutedigo de Seguros Seccioacuten 18711) La Compantildeiaacute de Seguros American Claims Management Inc considera que toda persona que participa en este tipo de fraude debe ser castigado con toda la fuerza de la ley incluyendo SENTENCIAS DE CARCEL

INSTRUCTIONS FOR IMPLEMENTING THE ACM MEDICAL PROVIDER NETWORK

Use the following steps to ensure that each employee is properly educated and notified about the

operation of a Medical Provider Network (MPN) If the employee is not properly educatednotified of the

MPN or ACM cannot show proof an injured employee was notified we may be unable to direct their

medical treatment within the MPN

HOW TO OBTAIN ACM MPN ENROLLMENT MATERIALS

The following American Claims Management (ACM) MPN enrollment materials are available online in

English and Spanish

1 Employee Notification of Rights

2 MPN Employee Notification Affidavit to document the posting advisement of the Notification of

Rights and Posting Notice

3 MPN Implementation Notice to New Employees (to be provided to new hires on or after 10-8-10)

4 Posting Notice (DWC7) (to be posted next to the Employee Notification of Rights)

To Access forms online

1 Go to the ACM website at wwwacmclaimscom

2 Under Report a Claim choose ldquoWorkersrsquo Compensationrdquo

3 Click on ldquoFormsrdquo

4 Choose a state

5 Under MPN Forms select a insurance company

6 Available in English and Spanish versions are the Employee Notification of Rights the Employee

Notification Affidavit the MPN Implementation Notice to New Employees and Posting Notice

Note This information cannot be modified as it has been expressly approved by the State and deviations

are not permitted If you want to personalize the material for your company we suggest you do so via a

separate cover memo

HOW TO ENROLL YOUR CURRENT amp NEW EMPLOYEES IN THE ACM MPN

All current employees will need to immediately be notified of this new MPN The ldquoNotification Affidavitrdquo that

is included within the ldquoACM MPN Packetrdquo shall be signed by all employees as a receipt verification of the

MPN information Once the employee has signed the form you should keep this with their personnel file

and if the employee sustains an injury then provide a copy of the Affidavit with the first report of injury to

ACM The Notification Affidavit with your employeersquos signature and date provides ACM the necessary

documentation to ensure MPN medical control

There are several options available to you to ensure efficient distributiondocumentation of the MPN

Employee Notification Requirements

1 Immediately provide each employee with a posting advisement to direct employees to where the

Notification of Rights letter and Posting Notice are located This can be done in person via US

mail or a payroll stuffer Follow up with the employees to verify receipt of the signed Notification

Affidavit

2 Hold an all-employee meeting and hand out the Notification of Rights letter in a large group Have

each employee sign and return the Notification Affidavit at the end of the meeting

3 Send the Notification of Rights letter via e-mail to your all employee distribution list and copy

acmmpnacmclaimscom

For new employees hired on 10-8-10 or after include a completed lsquoMPN Implementation Notice to New

Employeesrsquo form within the ACM MPN Packet as apart of the new hire paperwork and secure the Affidavit

during new employee enrollment

HOW TO FIND A MEDICAL PROVIDER IN THE ACM MPN

If an employee is injured you must direct the injured worker to an MPN provider however in an

emergency situation always direct the injured worker to the nearest emergency room To find a provider

log on to our web site at wwwacmclaimscom


2 Click on the link ldquoMedical Provider Networkrdquo

INSTRUCCIONES PARA LA IMPLEMENTACIOacuteN DE LA RED DE PROVEEDORES MEacuteDICOS DE ACM

Realice los siguientes pasos para asegurar que cada empleado reciba instrucciones y notificaciones apropiadas acerca de la operacioacuten de una Red de Proveedores Meacutedicos (MPN por sus siglas en ingleacutes) Si el empleado no recibe instruccionesnotificaciones apropiadas de la MPN o ACM no puede mostrar evidencia de que un trabajador lesionado recibioacute notificacioacuten quizaacutes no podamos dirigir su tratamiento meacutedico dentro de la MPN

COacuteMO OBTENER MATERIALES DE INSCRIPCIOacuteN EN LA MPN DE ACM

Los siguientes materiales de inscripcioacuten de la MPN de American Claims Management (ACM) estaacuten disponibles en liacutenea en ingleacutes y espantildeol

1 Notificacioacuten de derechos del empleado 2 Declaracioacuten jurada de notificacioacuten al empleado de la MPN para documentar la publicacioacuten del aviso de

Notificacioacuten de Derechos y Notificacioacuten de Publicacioacuten 3 Notificacioacuten de Implementacioacuten a Empleados Nuevos de la MPN (que seraacute entregada a empleados recieacuten

contratados a partir del 08-OCT-10) 4 Notificacioacuten de publicacioacuten (DWC7) (que se publicaraacute luego de la Notificacioacuten de Derechos del Empleado)

Para acceder a los formularios en liacutenea

1 Visite el sitio Web de ACM wwwacmclaimscom 2 En ldquoReport a Claimrdquo (Informe un Reclamo) elija ldquoWorkersrsquo Compensationrdquo (Compensacioacuten del Trabajador) 3 Haga clic en ldquoFormsrdquo (Formularios) 4 Elija un estado 5 En ldquoMPN Formsrdquo (Formularios de MPN) seleccione una compantildeiacutea de seguros 6 La Notificacioacuten de Derechos la Declaracioacuten Jurada de Notificacioacuten al Empleado la Notificacioacuten de

Implementacioacuten de la MPN a Nuevos Empleados y la Notificacioacuten de Publicacioacuten estaacuten disponibles en versiones en ingleacutes y espantildeol

Nota Esta informacioacuten no puede ser modificada luego de ser expresamente aprobada por el Estado y no se permite ninguna desviacioacuten Si usted desea personalizar el material para su compantildeiacutea sugerimos hacerlo mediante un memorando de cobertura separada

COacuteMO INSCRIBIR A EMPLEADOS NUEVOS Y ACTUALES EN LA MPN DE ACM

Todos los empleados actuales necesitaraacuten recibir una notificacioacuten de inmediato acerca de esta nueva MPN La ldquoDeclaracioacuten Jurada de Notificacioacutenrdquo que se incluye dentro del ldquoPaquete de la MPN de ACMrdquo seraacute firmada por todos los empleados como acuse de recibo de la informacioacuten de la MPN Una vez que el empleado haya firmado el formulario usted debe conservarlo en su archivo de personal y si el empleado sufre una lesioacuten entonces enviacuteele una copia de la Declaracioacuten Jurada con el primer informe de lesioacuten a ACM La Declaracioacuten Jurada de Notificacioacuten junto con la firma y fecha de su empleado proporciona a ACM la documentacioacuten necesaria para asegurar el control meacutedico de la MPN Hay varias opciones disponibles para usted a fin de asegurar la distribucioacutendocumentacioacuten eficiente de los requisitos de Notificacioacuten al Empleado acerca de la MPN

1 Entregar de inmediato a cada empleado un aviso de publicacioacuten que dirija a los empleados al lugar donde se ubica la Carta de Notificacioacuten de Derechos y el Aviso de Publicacioacuten Esto se puede realizar en persona viacutea correo postal o folleto de planillas de pago Realizar el seguimiento de los empleados para verificar la recepcioacuten de la Declaracioacuten Jurada de Notificacioacuten firmada

2 Celebrar reuniones con todos los empleados y entregar la carta de Notificacioacuten de Derechos en un grupo grande Disponer que cada empleado firme y devuelva la Declaracioacuten Jurada de Notificacioacuten al final de la reunioacuten

3 Enviar la carta de Notificacioacuten de Derechos viacutea correo electroacutenico a su lista de distribucioacuten de empleado y una copia a acmmpnacmclaimscom

Para los empleados nuevos contratados a partir del 08-OCT-10 incluir el formulario de Notificacioacuten de Implementacioacuten a Empleados Nuevos de la MPNrdquo dentro del Paquete de la MPN de ACM como parte de los documentos del empleado Nuevo y asegurar la obtencioacuten de la Declaracioacuten Jurada durante la inscripcioacuten de cada empleado nuevo

COacuteMO HALLAR A UN PROVEEDOR MEacuteDICO EN LA MPN DE ACM

Si un empleado resulta lesionado usted debe dirigir al trabajador lesionado a un proveedor de la MPN sin embargo en una situacioacuten de emergencia siempre dirija al trabajador lesionado a la sala de emergencia maacutes cercana Para hallar a un proveedor iniciar sesioacuten en nuestro sitio Web wwwacmclaimscom

1 En ldquoReport a Claimrdquo (Informe un Reclamo) elija ldquoWorkersrsquo Compensationrdquo (Compensacioacuten del Trabajador) 2 Haga clic en el viacutenculo Medical Provider Network (Red de Proveedores Meacutedicos)

ACMclaimscom

MPN Implementation Notice to New Employees Effective October 8 2010

Notice to Employee

Unless you pre-designate a physician or medical group prior to injury your new

work injuries arising on or after _____________ will be treated by providers within the (Effective Date) Medical Provider Network (MPN) _______________________________ (MPN Name)

If you have an existing injury you may be required to change to a provider in the

MPN Check with your claims adjuster at American Claims Management Inc

(ACM) You may obtain more information about the MPN from the workersrsquo

compensation poster or from your employer

_______________________________________________________________________________

Notice to Employer

This MPN Implementation Notice must be provided to all new employees at the

time of hire The notice shall be provided in English and Spanish if employee is

Spanish-speaking The notice can be provided by mail or included on or with an

employeersquos paystubpaycheck or distributed through electronic means including

email if the employee has regular electronic access to email at work

ldquoEffective Daterdquo noted above is the date that the MPN information was posted

ldquoMPN Namerdquo ndash If you are unaware of the name of the MPN you can call the MPN

Helpdesk at (866) 671-5042

ACMclaimscom

Notificacioacuten de Implementacioacuten de Red de Proveedores Meacutedicos (MPN) para Empleados Nuevos

Fecha efectiva 8 de octubre de 2010

Notificacioacuten al Empleado

A menos que usted pre-designe a un meacutedico o grupo meacutedico antes de lesionarse sus nuevas lesiones laborales surgidas el diacutea ________________ o con posterioridad a

(Fecha efectiva) esa fecha seraacuten tratadas por proveedores comprendidos en la Red de Proveedores Meacutedicos (MPN por sus siglas en ingleacutes) ____________________________ (Nombre de la MPN)

Si usted tiene una lesioacuten existente puede que se le exija cambiarse a un proveedor de la MPN Verifique con su liquidador de reclamos en American Claims Management Inc (ACM) Usted podraacute tener mayores informaciones acerca de la MPN en el afiche de compensacioacuten a trabajadores o de parte de su empleador

_______________________________________________________________________________

Notificacioacuten al Empleador

La presente Notificacioacuten de Implementacioacuten de MPN deberaacute ser proporcionada a todos los empleados al momento de su contratacioacuten La notificacioacuten seraacute entregada en ingleacutes y espantildeol si el empleado es hispanoparlante La notificacioacuten podraacute ser entregada por correo o incluida en o conjuntamente con el comprobante de pagocheque de remuneracioacuten del empleado o distribuida por

medios electroacutenicos incluyendo correos electroacutenicos si el empleado tiene acceso habitual a correos electroacutenicos en su trabajo

La ldquoFecha Efectivardquo enunciada maacutes arriba es la fecha en que se publicoacute la informacioacuten sobre la MPN

ldquoNombre de la MPNrdquo ndash Si usted no estaacute al tanto del nombre de la MPN puede llamar a la Mesa de Ayuda de MPN al nuacutemero (866) 671-5042

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446

Employee Notification Affidavit

In order to provide the most timely and suitable quality medical care in the event of an injury on the job we have instituted a Medical Provider Network for Workersrsquo Compensation The following procedures must be followed for all work-related injuries and

illnesses bull Report promptly any work-related injury to the supervisor bull For a referral to a medical provider specialist contact your employer or

claims adjuster bull Ensure all medical treatment is handled only through the MPN (Medical

Provider Network) unless otherwise authorized bull Direct all questions about the level of care to the PCP (Primary Care

Physician) who is the focal point for all medical treatment bull A directory of medical care providers is available upon request through my

employer

Please sign below to indicate that you have read and understand the above procedures as well as the Initial Written MPN Employee Notification in the event of an injury and your duties under our Medical Provider Network

____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________

Employee Signature Employer Signature _____________________________________________

Employee Number

A COPY OF THE MPN DIRECTORY IS AVAILABLE FROM YOUR EMPLOYER OR ADJUSTER UPON YOUR REQUEST

ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446

Notificacioacuten Declaracioacuten Jurada de Empleados

Para brindar atencioacuten meacutedica de la maacutes raacutepida y de apropiada calidad en el evento de una lesioacuten ocasionada en el trabajo hemos instituido una Red de Proveedores Meacutedicos para Compensacioacuten Laboral

Los procedimientos siguientes deben ser seguidos para todas las lesiones y enfermedades ocasionadas en el trabajo bull Reporte inmediatamente a su supervisor cualquier lesioacuten ocasionada en el trabajo

bull Para una referencia a un meacutedico especialista comuniacutequese con su

empleador o ajustador de reclamos bull Cercioacuterese que todo tratamiento meacutedico sea manejado uacutenicamente por la

MPN (Red de Proveedores Meacutedicos) a menos que de otro modo autorizado bull Dirija toda pregunta sobre el nivel de cuidado al PCP (Primary Care

Physician ndash Meacutedico de Cabecera) quien es el punto de referencia para todo tratamiento meacutedico

bull Un directorio de proveedores de cuidado meacutedico estaacute disponible al solicitarlo a traveacutes de mi empleador bull Un directorio de proveedores de atencioacuten meacutedica estaacute disponible previa solicitud a traveacutes de mi empleador

Por favor firme abajo para indicar que usted ha leiacutedo y entendido los procedimientos anteriores asiacute como la Initial Written MPN Employee Notification en el caso de una lesioacuten y sus funciones en virtud de nuestra Red de proveedores meacutedicos

____________________________________ __________________________________ Imprima Nombre Fecha _____________________________________________ ___________________________________________

Firma de empleado Firma de empleador _____________________________________________

Nuacutemero de empleado

UNA COPIA DEL DIRECTORIO DE LA MPN ESTAacute DISPONIBLE DE SU EMPLEADOR O AJUSTADOR AL SOLICITARLO

Important Information about Medical Care if you have a

Work-Related Injury or Illness

Initial Written MPN Employee Notification

(Title 8 California Code of Regulations section 976712)

California law requires your employer to provide and pay for medical treatment if you are injured at work

Your employer has chosen to provide this medical care by using a Workersrsquo Compensation physician network

called a Medical Provider Network (MPN) This MPN is administered by American Claims Management Inc

Your employerrsquos workersrsquo compensation carrier is Lincoln General Insurance Company This notification tells

you what you need to know about the MPN program and describes your rights in choosing medical care for

work-related injuries and illnesses

bull What is a MPN

A Medical Provider Network (MPN) is group of health care providers (physicians and other medical providers)

used by your employer to treat workers injured on the job Each MPN must include a mix of doctors

specializing in work-related injuries and doctors with expertise in general areas of medicine

MPNs must allow employees to have a choice of provider(s)

bull How do I find out which doctors are in my MPN

The contact for your MPN is

Title MPN Help Desk

Address PO Box 85251 San Diego CA 92186

Telephone Number (866) 671-5042

Email address wwwACMClaimscom

The MPN contact listed in this notification will be able to answer your questions about the MPN and will help

you obtain a regional list of all MPN doctors in your area At minimum the regional listing must include a list of

all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the

county where you live andor work You may choose which list you wish to receive

You can get the list of MPN providers by calling the MPN contact or by going to our website at

wwwACMClaimscom The complete provider directory is ldquoAmerican Claims Management Inc MPNrdquo

You also have the right to a complete listing of all of the MPN providers upon request

bull What happens if I get injured at work

In case of an emergency you should call 911 or go to the closest emergency room

If you are injured at work notify your employer as soon as possible Your employer will provide you with a

claim form When you notify your employer that you have had a work-related injury your employer or insurer

will make an initial appointment with a doctor in the MPN

bull How do I choose a provider

After the first medical visit you may continue to be treated by this doctor or you may choose another doctor

from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury

If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist If you

need help in choosing a doctor you may call the MPN Contact listed above

bull Can I change providers

Yes You can change providers within the MPN for any reason but the providers you choose should be

appropriate to treat your injury

bull What standards does the MPN have to meet

The MPN has providers for the following for the entire state of California excluding Alpine county

The MPN must give you a regional list of providers that includes at least three physicians in each specialty

commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary

physicians within 15 miles and specialists within 30 miles If you live in a rural area there may be a different

standard

The MPN must provide initial treatment within 3 days You must receive specialist treatment within 20 days of

your request If you have trouble getting an appointment contact the MPN

bull What if there are no MPN providers where I am located

If you are a current employee living in a rural area or temporarily working or living outside the MPN service

area or you are a former employee permanently living outside the MPN service area the MPN or your

treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you

to choose your own doctor outside of the MPN network Contact your MPN for assistance in finding a

physician or for additional information

bull What if I need a specialist not in the MPN

If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist

outside of the MPN

bull What if I disagree with my doctor about medical treatment

If you disagree with your doctor or wish to change your doctor for any reason you may choose another

doctor within the MPN

If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second

opinion from another doctor within the MPN If you want a second opinion you must contact the MPN and

tell them you want a second opinion The MPN should give you at least a regional MPN provider list from

which you can choose a second opinion doctor To get a second opinion you must choose a doctor from

the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment

date and the MPN will send the doctor a copy of your medical records You can request a copy of your

medical records that will be sent to the doctor

If you do not make an appointment within 60 days of receiving the regional provider list you will not be

allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating

physician

If the second opinion doctor feels that your injury is outside of the type of injury he or she normally treats the

doctors office will notify your employer or insurer You will get another list of MPN doctors or specialists so you

can make another selection

If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will

go through the same process you went through for the second opinion

Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list

then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this

treating physician

If you disagree with the third opinion doctor you may ask for an Independent Medical Review (IMR) Your

employer or MPN contact person will give you information on requesting an Independent Medical Review

and a form at the time you request a third opinion

If either the second or third opinion doctor agrees with your need for a treatment or test you will be allowed

to receive that medical service from a provider inside the MPN including the second or third opinion

physician

If the Independent Medical Reviewer supports your need for a treatment or test you may receive that care

from a doctor inside or outside of the MPN

bull What if I am already being treated for a work-related injury before the MPN begins

Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being

temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is

transferred into the MPN

If you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If

you have questions about predesignation ask your supervisor) If your current doctor is not or does not

become a member of the MPN then you may be required to see a MPN physician

If your employer decides to transfer you into the MPN you and your primary treating physician must receive a

letter notifying you of the transfer

If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a

year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care

into the MPN are in the box below

You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be

transferred into the MPN ask your primary treating physician for a medical report on whether you have one

of the four conditions stated above to qualify for a postponement of your transfer into the MPN

Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report

on your condition If your primary treating physician does not give you the report within 20 days of your

request the employer can transfer your care into the MPN and you will be required to use a MPN physician

You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care

If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can

dispute it See the complete transfer of care policy for more details on the dispute resolution process

For a copy of the entire transfer of care policy ask your MPN Contact

Can I Continue Being Treated By My Doctor

You may qualify for continuing treatment with your non-MPN provider (through transfer

of care or continuity of care) for up to a year if your injury or illness meets any of the

following conditions

(Acute) The treatment for your injury or illness will be completed in less than 90 days

(Serious or chronic) Your injury or illness is one that is serious and continues for at least 90

days without full cure or worsens and requires ongoing treatment You may be allowed

to be treated by your current treating doctor for up to one year until a safe transfer of

care can be made

(Terminal) You have an incurable illness or irreversible condition that is likely to cause

death within one year or less

(Pending Surgery) You already have a surgery or other procedure that has been

authorized by your employer or insurer that will occur within 180 days of the MPN

effective date or the termination of contract date between the MPN and your doctor

bull What if I am being treated by a MPN doctor who decides to leave the MPN

Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can

temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer

participating in the MPN

If your employer decides that you do not qualify to continuing your care with the non-MPN provider you and

your primary treating physician must receive a letter of notification

If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before

you must switch to MPN physicians These conditions are set forth in the box above ldquoCan I Continue Being

Treated By My Doctorrdquo

You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN

provider If you want to continue treating with the terminated doctor ask your primary treating physician for

a medical report on whether you have one of the four conditions stated in the box above to see if you qualify

to continue treating with your current doctor temporarily

Your primary treating physician has 20 days from the date of your request to give you a copy of hisher

medical report on your condition If your primary treating physician does not give you the report within 20

days of your request the employer can transfer your care into the MPN and you will be required to use a MPN

physician


into the MPN If you or your employer disagrees with your doctorrsquos report on your condition you or your

employer can dispute it See the complete Continuity of Care policy for more details on the dispute

resolution process

For a copy of the entire Continuity of Care policy ask your MPN Contact

bull What if I have questions or need help

bull MPN Contact You may always contact the MPN Contact if you need help or an explanation

about your medical treatment for your work-related injury or illness


Title MPN Help Desk



Employerrsquos MPN website wwwACMClaimscom

Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN

the notification process or your medical treatment after a work-related injury or illness you can call DWCrsquos

Information and Assistance at 1-800-736-7401 You can also go to DWCrsquos website at wwwdircagovdwc

and click on ldquomedical provider networksrdquo for more information about MPNs

Independent Medical Review If you have questions about the Independent Medical Review process

contact the Division of Workersrsquo Compensationrsquos Medical Unit at

DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900

Keep this information in case you have a work-related injury or illness

Notificacioacuten Concluir Escrita del Empleado sobre la Red de Proveedores Meacutedicos

(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)

La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador ha elegido a proporcionarle este cuidado meacutedico utilizando una

red de meacutedicos de Compensacioacuten de Trabajadores llamada Red de Proveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por American Claims Management Inc El nombre de la compantildeiacutea de seguros de Compensacioacuten de Trabajadores de su empleador es Lincoln General Insurance Company Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo

bull iquestQueacute es una MPN Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia meacutedica (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones

de trabajo y meacutedicos expertos en areas de meacutedicina general Las MPNs deben permitir que los empleados tengan una seleccioacuten de proveedor(es) bull iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN

El contacto para su MPN es Tiacutetulo MPN Help Desk Direccioacuten PO Box 85251 San Diego CA 92186 Nuacutemero de Teleacutefono (866) 671-5042 Correo electroacutenico wwwACMClaimscom

El contacto de la MPN indicado en esta notificacioacuten podraacute contestarle sus preguntas sobre la MPN y le ayudaraacute a obtener una lista regional de los meacutedicos de la MPN en su area Por lo miacutenimo la lista regional debe incluir una lista de todos los proveedores de la MPN dentro de 15 millas de su lugar de trabajo yo residencia o una lista de todos los proveedores de la MPN dentro del condado donde usted vive yo trabaja Usted puede elegir cual lista quiere recibir

Puede obtener la lista de los proveedores de la MPN llamando al contacto de la MPN o puede ir a nuestra paacutegina web en el wwwACMClaimscom La contrasentildea para el directorio completo de proveedores es ldquoAmerican Claims Management Inc MPNrdquo Tambieacuten tiene derecho a una lista completa de todos los proveedores de la MPN si la pide

bull iquestQueacute pasa si me lastimo en el trabajo En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercana Si se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una

lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN

Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo

bull iquestCoacutemo escojo un proveedor Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir

otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito bull iquestPuedo cambiar de proveedor Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten bull iquestQueacute requisitos debe tener la MPN

La MPN tiene proveedores en los siguentes para todo el estado de California La MPN tiene que proporcionarle una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primarios dentro de 15 millas y especialistas dentro de 30 millas Si vive en una area rural puede haber un requisito diferente

La MPN debe proporcionarle tratamiento inicial dentro de 3 diacuteas Debe recibir tratamiento del especialista dentro de 20 diacuteas de su peticioacuten Si tiene algun problema en obtener una cita pongase en contacto con la MPN bull iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su MPN para asistencia enencontrar un meacutedico o para informacioacuten

adicional bull iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN

bull iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN

Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN y decirles que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la

MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico

Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento

recomendado por el meacutedico que lo estaacute atendiendo Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten

Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo

Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o la persona de contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted pida la tercera opinioacuten

Si el meacutedico de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute permitido recibir el servicio meacutedico de un proveedor dentro de la MPN incluyendo los meacutedicos de la segunda o tercera opinioacuten Si el meacutedico que hace la Revisioacuten Meacutedica Independiente corrobora su necesidad para algun tratamiento o anaacutelisis usted podraacute recibir ese cuidado de un meacutedico dentro o fuera de la MPN

bull iquestQueacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que

determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN Si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor) Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado

ver a un meacutedico de la MPN Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la

MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten en la caja debajo

Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN

El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN

Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa Para una copia del plan entero sobre la transferencia de cuidado preguntele a su contacto de la

MPN bull iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual

con su meacutedico si su meacutedico ya no estaacute participando en la MPN Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta de notificacioacuten Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico

hasta por un antildeo antes de que tenga que cambiar a un meacutedico de la MPN Estos requisitos estaacuten expuestos en la caja descrita arriba ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo

iquestPuedo Continuar Ser Tratado Por Mi Meacutedico Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por tranferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguentes condiciones

bull (Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas

bull (Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una tranferencia de cuidado segura pueda ser hecha

bull (Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos

bull (Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico

Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este

meacutedico pidale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro

de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes

detalles sobre el proceso de resolucioacuten de disputa Para una copia del plan de la Continuidad de Cuidado entero preguntele a su Contacto de la MPN bull iquestQueacute tal si tengo preguntas o necesito ayuda

bull El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si necesita ayuda o una explicacioacuten sobre su tratamiento meacutedico para su lesioacuten o enfermedad de trabajo contacto para su MPN es Tiacutetulo MPN Help Desk

Direccioacuten PO Box 85251 San Diego CA 92186 Nuacutemero de Teleacutefono (866) 671-5042 La paacutegina web de la MPN del empleador wwwACMClaimscom

bull La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene algun intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten o enfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs

bull Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en

DWC Medical Unit PO Box 71010 Oakland CA 94612

(510) 286-3700 or (800) 794-6900

Guarde esta informacioacuten en caso que tenga una lesioacuten o enfermedad de trabajo

21_ON_EMPLOYERS_PREMISES Off

13_DATE_RETURNED_TO_WORK

32_DATE_OF_I_PTH_mm_ddio

34sex 34 SEX

36 36 DATE OF HIRE (mmddyy)

33 33 HOME ADDRESS (Number Street CityZip)

34 Off

39 Off

18I_PAID_FULL_DAYS_WAGES_FO Off

24_EQUIPMENT_MATERIALS_AN

3_LOCATION_ifdifferent_fr

Completed_By_type_or_prin

19_SPECIFIC_INJURYILLNESS

37a Off

34female Female

27a 27a Phone Number

16_SALARY_BEING_CONTINUED Off

28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO

27 27 Name and address of physician (number street city zip)

7_DATE_OF_INJURY__ONSET_O

28 28 Hospitalized as an inpatient overnight

2_MAILING_ADDRESS_Number

29 Off

20_LOCATION_WHERE_EVENT_O

31_SOC_A_SECUPITi_NUMBER

30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER

32 32 DATE OF BIRTH (mmddyy)

31 31 SOCIAL SECURITY NUMBER

18_DATE_EMPLOYEE_PROVIDED

days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E

4_NATURE_OF_BUSINESS_eg_P

37b-under-chat-class-code

26_HOW_INJURY_ILLNESS

17_DATE_OF_EMPLOYERS_KNOW

Other_Govt_Specify

35_OCC_UPAT_ON_Ppqj_a_on

Please_complete_in_tripli

7_DATE_OF_INJURY__ONSET_1

27_name _address_of_physician

11 Off

FillText1

29text 29 Employee treated in emergency room

Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2

22_DEPARTMENT_WHERE_EVENT

29_HOSP_TA_ZED_AS_AN_NAl

hours_per_day

36_DATE_OF_H_RE_mmiddlyy

33_HOME_ADDRESS_IN_be_Sto

33a 33a PHONE NUMBER

8_pm

27_Phone_411h

3aLocation_Code

10_IF_EMPLOYEE_DIED_DATE

28yes_text If yes then name and address of hospital (number street city zip)

per

25_SPECIFIC_ACTIVITY_THE

28no No

34male Male

29no No



ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8887992919

FAX 7608274040

CA License 2C37446

How to Report a Work-Related Injury

When an employee has been injured at work how do you take control of the

situation Follow these three easy steps to immediately file your claim

If the event is a medical emergency seek immediate care for the employee from the

nearest emergency medical provider or facility For non emergencies your Medical

Provider Network is the American Claims Management MPN You can access the

medical provider network for your injured employees by going to our website at

wwwACMClaimscom or call the MPN Help Desk at (866) 671-5042

Report a Claim 24 hrs7 days

Online ACMClaimscom (Preferred)

Phone 866-671-5042

Fax 619-744-5030

Email reportaclaimacmclaimscom

Distribute to the Injured Employee at Time of Injury

Form DWC-1

Facts About Workers Compensation

Initial Written Employee Notification Re MPN

1 Get The Facts 2 Gather All Supporting

Information

3 Report the Claim

Immediately

Find out as much as you

can about the injury and

obtain the employeersquos

personnel file whenever

possible

Obtain as much supplemental

information as you can before you

report the claim

bull Name Address Phone

bull Date of Birth

bull Social Security Number

bull Date of Hire

bull Wage Information

Donrsquot delay in calling

because you donrsquot have all

the information Timely

reporting is essential You can

gather and report any missing

information at a later date

ACMclaimscom


San Diego CA 92101

TOL 8887992919

FAX 7608274040

CA License 2C37446



Via Phone - 866-671-5042

Via Fax - 619-744-5030













PO Box 85251

San Diego CA 92186



Fax Number 619-744-5030




















































________________________________________________________________________________________________________________________________________


________________________________________________________________________________________________________________________________________










________________________________________________________________________________________________________________________________________













EMPLOYER




INJURY


Yes No


OR

ILLNESS

PART OF BODY


EMPLOYEE




part-time

EXTENT OF INJURY






OSHA CASE NO

FATALITY






CASE NUMBER

OWNERSHIP

INDUSTRY






Yes No


DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY




SOURCE

EVENT

SECONDARY SOURCE

Elsa Q Gomez












Doctor


Telephone

Employee Name

Employee Address

Employee Signature

Date




Employee Signature

Employee ID

Date



Phone Number


Fax

Email

Physician License

Physician Tax ID









Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



ACMclaimscom


San Diego CA 92101

TOL 8887992919

FAX 7608274040

CA License 2C37446



Via Phone - 866-671-5042

Via Fax - 619-744-5030













PO Box 85251

San Diego CA 92186



Fax Number 619-744-5030




















































________________________________________________________________________________________________________________________________________


________________________________________________________________________________________________________________________________________










________________________________________________________________________________________________________________________________________













EMPLOYER




INJURY


Yes No


OR

ILLNESS

PART OF BODY


EMPLOYEE




part-time

EXTENT OF INJURY






OSHA CASE NO

FATALITY






CASE NUMBER

OWNERSHIP

INDUSTRY






Yes No


DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY




SOURCE

EVENT

SECONDARY SOURCE

Elsa Q Gomez












Doctor


Telephone

Employee Name

Employee Address

Employee Signature

Date




Employee Signature

Employee ID

Date



Phone Number


Fax

Email

Physician License

Physician Tax ID









Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No






















































________________________________________________________________________________________________________________________________________


________________________________________________________________________________________________________________________________________










________________________________________________________________________________________________________________________________________













EMPLOYER




INJURY


Yes No


OR

ILLNESS

PART OF BODY


EMPLOYEE




part-time

EXTENT OF INJURY






OSHA CASE NO

FATALITY






CASE NUMBER

OWNERSHIP

INDUSTRY






Yes No


DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY




SOURCE

EVENT

SECONDARY SOURCE

Elsa Q Gomez












Doctor


Telephone

Employee Name

Employee Address

Employee Signature

Date




Employee Signature

Employee ID

Date



Phone Number


Fax

Email

Physician License

Physician Tax ID









Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No






EMPLOYER




INJURY


Yes No


OR

ILLNESS

PART OF BODY


EMPLOYEE




part-time

EXTENT OF INJURY






OSHA CASE NO

FATALITY






CASE NUMBER

OWNERSHIP

INDUSTRY






Yes No


DAILY HOURS

DAYS PER WEEK

WEEKLY HOURS

WEEKLY WAGE

COUNTY

NATURE OF INJURY




SOURCE

EVENT

SECONDARY SOURCE

Elsa Q Gomez












Doctor


Telephone

Employee Name

Employee Address

Employee Signature

Date




Employee Signature

Employee ID

Date



Phone Number


Fax

Email

Physician License

Physician Tax ID









Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No














Doctor


Telephone

Employee Name

Employee Address

Employee Signature

Date




Employee Signature

Employee ID

Date



Phone Number


Fax

Email

Physician License

Physician Tax ID









Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No











Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






Telephone



Employee Signature

Date



simplified versions

secondary option



























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No





























8666715042














































Nombre del doctor


Teleacutefono

Nombre del Empleado


Firma del Empleado

Fecha




Firma del Empleado


Fecha





Fax



















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No


















Teleacutefono



Firma del Empleado

Fecha



simplified versions

secondary option

Anaheim (714) 414-1801


Eureka (707) 441-5723

Fresno (559) 445-5355

Goleta (805) 968-4158

Long Beach (562) 590-5240

Los Angeles (213) 576-7389


Oakland (510) 622-2861

Oxnard (805) 485-3528

Pomona (909) 623-8568

Redding (530) 225-2047

Riverside (951) 782-4347


Salinas (831) 443-3058


San Diego (619) 767-2082


San Jose (408) 277-1292


Santa Ana (714) 558-4597

Santa Rosa (707) 576-2452

Stockton (209) 948-7980

Van Nuys (818) 901-5367






BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No








BenefitsInclude


ClaimsAdministrator


866-671-5042



866-671-5042 FAX 619-744-5030










BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No












BeneficiosIncluyen







TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No




TOLL FREE

WORKERSCOMPENSATION

CLAIMSFRAUD

REWARD

1000$








Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No




Ofrece

LLAMADA GRATIS


TRABAJADORES

RECOMPENSA

1000$















English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No










English and Spanish










4 Choose a state






separate cover memo













Affidavit




acmmpnacmclaimscom






























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No























ACMclaimscom


Notice to Employee







_______________________________________________________________________________

Notice to Employer








Helpdesk at (866) 671-5042

ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



ACMclaimscom







_______________________________________________________________________________






ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446







employer


____________________________________ __________________________________ Print Name Date _____________________________________________ ___________________________________________


Employee Number


ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



ACMclaimscom

ACMclaimscom

PO Box 85251

San Diego CA 92186

TOL 8666715042

FAX 6197445030

CA License 2C37446
























bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No













bull What is a MPN







Title MPN Help Desk





























standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No










standard











outside of the MPN













physician








treating physician






physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No





physician

































care can be made






















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



















physician




resolution process






Title MPN Help Desk










DWC Medical Unit

PO Box 71010

Oakland CA 94612

(510) 286-3700 or (800) 794-6900



















































(510) 286-3700 or (800) 794-6900





34sex 34 SEX



34 Off

39 Off






37a Off

34female Female



28yes Yes

20a_COUNTY

2a_Phone_Number

Ia_Policy_Number

30_EMPLO_CC_NAME

23 Off

AM1

OSHA_CASE_NO





29 Off



30 30 EMPLOYEE NAME

6 Off

33a_PHONE_NUMBER




days_per_week1

CheckBox1 Off

29yes Yes

CheckBox2 Off

E





Other_Govt_Specify





11 Off

FillText1


Jills_Phone_No

1_FIRM_NAME

5_stae_unemployment

8_AM2



hours_per_day




8_pm

27_Phone_411h

3aLocation_Code



per


28no No

34male Male

29no No



Dear Policyholder, You have purchased Workersâ€™ Compensation

Documents

Transcript of Dear Policyholder, You have purchased Workersâ€™ Compensation