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Workers' Compensation Claim Form(DWC 1)&Notice of Potential Eligibility
<br /> Formulario de Reclamo de Compensacion de Trahajadores(DWC 1)y Notificacion de Posihle Elegihilidad
<br /> If you are injured or become ill,either physically or mentally,because of your job, Si Ud. se lesiona o se enferma, ya sea fisicamente o mentalmente, debido a su
<br /> including injuries resulting from a workplace crime, you may be entitled to trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es
<br /> workers' compensation benefits. Use the attached form to file a workers' posible que Ud. tenga derecho a beneficios de compensaci6n de trabajadores.
<br /> compensation claim with your employer.You should read all of the information Utilice el formulario adjunto Para presentar un reclamo de compensaci6n de
<br /> below.Keep this sheet and all other papers for your records.You may be eligible trabajadores con su empleador. Ud. debe leer toda la informacion a
<br /> for some or all of the benefits listed depending on the nature of your claim.If you continuaci6n.Guarde esta hoja y todos los demas documentos Para sus archivos.
<br /> file a claim,the claims administrator,who is responsible for handling your claim, Es posible que usted reuna los requisitos Para todos los beneficios, o parte de
<br /> must notify you within 14 days whether your claim is accepted or whether estos,que se enumeran dependiendo de la indole de su reclamo.Si usted presenta
<br /> additional investigation is needed. un reclamo,1 administrador de reclamos,quien es responsable por el manejo de su
<br /> To file a claim,complete the"Employee"section of the form,keep one copy and reclamo,debe notificarle dentro de 14 dias si se acepta su reclamo o si se necesita
<br /> give the rest to your employer. Do this right away to avoid problems with your investigacion adicional.
<br /> claim.In some cases,benefits will not start until you inform your employer about Para presentar un reclamo, Ilene la secci6n del formulario designada Para el
<br /> your injury by filing a claim form.Describe your injury completely.Include every "EmPleado," guarde una copia, y dele el resto a su empleador. Haga esto de
<br /> part of your body affected by the injury. If you mail the form to your employer, inmediato Para evitar problemas con su reclamo. En algunos casos,los beneficios
<br /> use first-class or certified mail. If you buy a return receipt, you will be able to no se iniciaran hasta que usted le informe a su empleador acerca de su lesion
<br /> prove that the claim form was mailed and when it was delivered. Within one mediante la presentaci6n de un formulario de reclamo. Describa su lesion por
<br /> working day after you file the claim form, your employer must complete the completo.Incluya cada parte de su cuerpo afectada por la lesion.Si usted le envia
<br /> "Employer" section, give you a dated copy,keep one copy, and send one to the por correo el formulario a su empleador,utilice primera clase o correo certificado.
<br /> claims administrator. Si usted compra un acuse de recibo,usted podrA demostrar que el formulario de
<br /> reclamo fire enviado por correo y cuando fire entregado.Dentro de un dia laboral
<br /> Medical Care: Your claims administrator will pay for all reasonable and despues de presenter el formulario de reclamo, su empleador debe completer la
<br /> necessary medical care for your work injury or illness. Medical benefits are secci6n designada pare el"Empleador,"le darA a Ud.una copia fechada,guardarA
<br /> subject to approval and may include treatment by a doctor, hospital services, una copia,y enviarA una al administrador de reclamos.
<br /> physical therapy, lab tests, x-rays, medicines, equipment and travel costs. Your
<br /> claims administrator will pay the costs of approved medical services directly so Atenci6n MMica: Su administrador de reclamos pagarA por toda la atenci6n
<br /> you should never see a bill.There are limits on chiropractic,physical therapy,and medica razonable y necesaria Para su lesion o enfermedad relacionada con el
<br /> other occupational therapy visits. trabajo. Los beneficios medicos estan sujetos a la aprobaci6n y pueden incluir
<br /> tratamiento por parte de un medico,los servicios de hospital,la terapia fisica,los
<br /> The Primary Treatina Physician (PTP) is the doctor with the overall anAlisis de laboratorio,las medicinal,equipos y gastos de viaje. Su administrador
<br /> responsibility for treatment of your injury or illness. de reclamos pagarA directamente los costos de los servicios medicos aprobados de
<br /> • If you previously designated your personal physician or a medical group, manera que usted nunca verA una factura. Hay limites en terapia quiropractica,
<br /> you may see your personal physician or the medical group after you are
<br /> injured. fisica y otras visitas de terapia ocupacional.
<br /> • If your employer is using a medical provider network(MPN)or Health Care El Medico Primario que le Atiende(Primary Treating,Physician-PTP) es el
<br /> Organization(HCO),in most cases,you will be treated in the MPN or HCO medico con la responsabilidad total Para tratar su lesion o enfermedad.
<br /> unless you predesignated your personal physician or a medical group. An Si usted design previamente a su medico personal o a un grupo medico,
<br /> MPN is a group of health care providers who provide treatment to workers usted podrA ver a su medico personal o grupo medico despues de lesionarse.
<br /> injured on the job. You should receive information from your employer if . Si su empleador estd utilizando una red de proveedores medicos (Medical
<br /> you are covered by an HCO or a MPN. Contact your employer for more provider Network-MPN) o una Organizacion de Cuidado Medico (Health
<br /> information. Care Organization-HCO),en la mayoria de los casos,usted sera tratado en
<br /> • If your employer is not using an MPN or HCO, in most cases,the claims la MPN o HCO a menos que usted hizo una designaci6n previa de su medico
<br /> administrator can choose the doctor who first treats you unless you
<br /> predesignated your personal physician or a medical group. personal o grupo medico. Una MPN es un grupo de proveedores de
<br /> • If your employer has not put up a poster describing your rights to workers' asistencia medica quien da tratamiento a los trabajadores lesionados en el
<br /> compensation, you may be able to be treated by your personal physician trabajo. Usted debe recibir informaci6n de su empleador si su tratamiento es
<br /> right after you are injured. cubierto por una HCO o una MPN. Hable con su empleador Para mas
<br /> Within one working day after you file a claim form,your employer or the claims informacion.
<br /> administrator must authorize up to$10,000 in treatment for your injury,consistent Si su empleador no estd utilizando una MPN o HCO, en la mayoria de los
<br /> with the applicable treating guidelines until the claim is accepted or rejected. If casos, el administrador de reclamos puede elegir el medico que to atiende
<br /> the employer or claims administrator does not authorize treatment right away,talk primero a menos de que usted hizo una designaci6n previa de su medico
<br /> to your supervisor,someone else in management,or the claims administrator.Ask personal o grupo medico.
<br /> • Si su empleador no ha colocado un cartel describiendo sus derechos Para la
<br /> for treatment to be authorized right now, while waiting for a decision on your compensaci6n de trabajadores,Ud.puede ser tratado por su medico personal
<br /> claim. If the employer or claims administrator will not authorize treatment, use c m compensaci6n
<br /> despues de es,Ulesio arse.
<br /> your own health insurance to get medical care. Your health insurer will seek
<br /> reimbursement from the claims administrator.If you do not have health insurance, Dentro de un dia laboral despues de que Ud.Presente un formulario de reclamo,
<br /> there are doctors, clinics or hospitals that will treat you without immediate su empleador o el administrador de reclamos debe autorizar hasta $10000 en
<br /> payment.They will seek reimbursement from the claims administrator. tratamiento Para su lesion, de acuerdo con las pautas de tratamiento aplicables,
<br /> hasta que el reclamo sea aceptado o rechazado. Si el empleador o administrador
<br /> Switching to a Different Doctor as Your PTP: de reclamos no autoriza el tratamiento de inmediato, liable con su supervisor,
<br /> • If you are being treated in a Medical Provider Network(MPN), you may alguien mas en la gerencia, o con el administrador de reclamos. Pida que el
<br /> switch to other doctors within the MPN after the first visit. tratamiento sea autorizado ya mismo, mientras espera una decision sobre su
<br /> • If you are being treated in a Health Care Organization (HCO), you may
<br /> switch at least one time to another doctor within the HCO.You may switch reclamo. Si el empleador o administrador de reclamos no autoriza el tratamiento,
<br /> to a doctor outside the HCO 90 or 180 days after your injury is reported to utilice su propio seguro medico Para recibir atenci6n medica. Su compaiiia de
<br /> your employer (depending on whether you are covered by employer- seguro medico buscarA reembolso del administrador de reclamos. Si usted no
<br /> provided health insurance). tiene seguro medico, hay medicos, clinicas u hospitales que to trataran sin Pago
<br /> • If you are not being treated in an MPN or HCO and did not predesignate, inmediato. Ellos buscaran reembolso del administrador de reclamos.
<br /> you may switch to a new doctor one time during the first 30 days after your
<br /> injury is reported to your employer. Contact the claims administrator to Cambiando a otro Medico tratamiento en una Red de Proveedores Medicos
<br /> ario o PTP:
<br /> Si usted estd recibiendo
<br /> switch doctors.After 30 days,you may switch to a doctor of your choice if tr
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