You may become responsible for the medical costs of treatment for your illness or condition with the provider listed below if (1) you fail to prosecute the claim for workers’ compensation or (2) it is determined by the Workers’ Compensation Board that the illness or condition which required treatment was not a result of a compensable workplace accident or occupational disease or (3) if an agreement is executed by you and approved pursuant to Workers’ Compensation Law §32 in which you waive your
right to medical benefits from the workers’ compensation carrier/self-insured employer for treatment/services performed after the date the agreement is approved. If any of the above events occurs, the provider may bill you directly instead of the employer or insurance carrier, and you will be responsible for the provider’s fees for services rendered.
I hereby acknowledge that I have read the above and understand the circumstances under which I may become responsible for payment.
Workers’ Compensation Board Regulation 325-1.23 permits your doctor or therapist to request that you sign this A-9 notice. By signing this notice, you acknowledge your obligation to pay the provider’s fees for the services you receive if it turns out that such fees are not legally required to be paid by your employer or its workers’ compensation insurance carrier and if such fees are not covered by other insurance. The employer or carrier may not be required to pay the doctor’s.fees if, for example, you fail to file a claim for workers’ compensation, or fail to notify your employer of your injury or illness, or fail to attend a Board hearing if your employer challenges your right to benefits. Even if you make all required efforts to prosecute your claim, the Workers’ Compensation Board may still find that you are not entitled to benefits. In such cases, this notice advises your health provider that you acknowledge your personal liability for payment of his/her bills.
Workers’ Compensation Law Section 32
The A-9 notice also covers instances in which a claimant with an existing valid workers’ compensation case comes to an agreement with his/her employer or its insurance carrier setting his/her case in accordance with Section 32 of the Workers’ Compensation Law. A Section 32 agreement may include a provision which relieves the employer or carrier of the liability to pay future medical bills associated with the case. Your health care provider may ask you to sign this A-9 notice to insure that you acknowledge your personal liability for payment of his/her bills if you have waived your right to future medical benefits under a Section 32 agreement.
If you have any questions, contact your attorney or licensed hearing representative, if you have one. You may also contact your local district office of the Workers’ Compensation Board.
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