Workers Compensation Policies for On-The Job-Injuries

Hilltop Medical Clinic is designated as the Primary Treating Physician (PTP) for your worker's compensation injury.  Your PTP will diagnose, treat and will decide the best work status for your specific injury.  Each time you are seen at the clinic, you must wait for the nurse to check you out after seeing the doctor.  The nurse will give you your work status, the date of your next visit and any medications that we can dispense here.  Since we have no narcotics, you may need to go to a pharmacy for any prescriptions that are not in our pharmacy formulary.

If the doctor gives you work restrictions, you are expected to speak to your employer as soon as possible to see if your employer can accommodate these restrictions. It is your responsibility to remember your recheck date at the clinic.  Not returning on the correct date may affect your worker's compensation benefits and may delay checks from your insurance company.  If your employer can not accommodate the restrictions they may decide to keep you off work. 

Chronic injuries:
It is the goal of our physicians to help you improve as much as possible and return to work as soon as possible.  Sometimes your injury may prevent you from returning to your normal work for quite some time.  If you can not improve to your pre-injury status, or if you have permanent restrictions,  the PTP may designate you Permanent and Stationary in regards to you injury.  Once this is done, you will need to have your family doctor or another physician see you for any treatment and follow-up.  Hilltop Medical Clinic will not continue to follow you for this injury and non-accute problems. 

Denied Claims:
If your claim is denied by the insurance company, it will be your financial responsibility to pay the clinic for any bill you incurred during your treatment for this injury.  You will also be responsible for any treatment by other healthcare professionals incurred for therapy you may have received.

Forms:
The doctor will complete required forms for your work comp injury free of charge.  There will be a $15 charge for any other forms related to your disability or your own personal finances.  It will be your responsibility to pay this charge at the time the forms are completed.

I have received the above information,

**SIGNATURE - TO BE DONE AT THE FRONT COUNTER ELECTRONICALLY 

AUTHORIZATION TO RELEASE MEDICAL INFORMATION

By law Hilltop Medical Clinic cannot release all your medical information concerning your injury or industrial accident without your written authorization.  To ensure all aspects of your injury are disclosed to the insurance company and to your employer it is important for you to give Hilltop Medical Clinic the authority to release all this information.  Each time you come to the clinic for a recheck, Hilltop Medical Clinic will send information to both the insurance company and your employer about your visit, treatment and work status. 

I hereby authorize Hilltop Medical Clinic to furnish to my insurance company, employer, Attorney or legal representative, all information concerning my industrial injury or accident.  This includes how I injured myself, medical history, treatment and work status.

Employer Name:  _____________________________________   Date: ENTER AT THE FRONT ELECTRONICALLY

**SIGNATURE - TO BE DONE AT THE FRONT COUNTER ELECTRONICALLY

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 WORKER'S COMPENSATION BENEFITS OR PAYMENTS IS GUILTY OF A FELONY.