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Notice To Employees-Injuries Caused By Work DWC 7 - California

Notice To Employees-Injuries Caused By Work Form. This is a California form and can be used in General Workers Comp .
 Fillable pdf Last Modified 1/28/2016
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STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation Notice to Employees--Injuries Caused By Work You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over). Benefits. Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, medicines, medical equipment and travel costs that are reasonably necessary to treat your injury. You should never see a bill. There are limits on chiropractic, physical therapy and occupational therapy visits. Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury. Permanent Disability (PD) Benefits: Payments if you do not recover completely and your injury causes a permanent loss of physical or mental function that a doctor can measure. Supplemental Job Displacement Benefit: A nontransferable voucher, if you are injured on or after 1/1/2004, your injury causes permanent disability, and your employer does not offer you regular, modified, or alternative work. Death Benefits: Paid to your dependents if you die from a work-related injury or illness. Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured. You must obtain their agreement to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees. If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or police department. If you need first aid, contact your employer. 2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you with a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer or claims administrator must authorize the provision of all treatment, up to ten thousand dollars, consistent with the applicable treatment guidelines, for your alleged injury until the claim is accepted or rejected. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesignated your personal physician or a medical group, you may see your personal physician or the medical group after you are injured. If your employer is using a medical provider network (MPN) or a health care organization (HCO), in most cases you will be treated within the MPN or HCO unless you predesignated a personal physician or medical group. An MPN is a group of physicians and health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information. If your employer is not using an MPN or HCO, in most cases the claims administrator can choose the doctor who first treats you when you are injured, unless you predesignated a personal physician or medical group. 3. 4. Medical Provider Networks. Your employer may be using an MPN, which is a group of health care providers designated to provide treatment to workers injured on the job. If you have predesignated a personal physician or medical group prior to your work injury, then you may go there to receive treatment from your predesignated doctor. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below: MPN website: ________________________________________________________________________________________________________________________ MPN Effective Date: _______________________ MPN Identification number: ___________________________________________ If you need help locating an MPN physician, call your MPN access assistant at: ___________________________________________ If you have questions about the MPN or want to file a complaint against the MPN, call the MPN Contact Person at: ______________ Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state. Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer): Claims Administrator____________________________________________________ Phone ________________________________ Workers' compensation insurer (Enter "self-insured" if appropriate) You can also get free information from a State Division of Workers' Compensation Information (DWC) & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll-free (800) 736-7401. Learn more information about workers' compensation online: www.dwc.ca.gov and access a useful booklet "Workers' Compensation in California: A Guidebook for Injured Workers." False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned. Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is
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