1 Designated Provider Notification Letter

BAN Electric Services, Inc.

New Employee Designated Provider Notification Letter

To: All Employees

From: BAN Electric Services, Inc.
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Subject: Designated Medical Providers for Work-Related Injuries and Illnesses

All employees must obtain treatment of work-related injuries and illnesses from one of the following medical providers:

1. Name: ROCKY MOUNTAIN MEDICAL GROUP--ENGLEWOOD

Address: 730 W HAMPDEN AVE STE 200

City, State & Zip: ENGLEWOOD, CO 80110

Phone: 303-762-0900
2. Name: CONCENTRA MEDICAL CENTERS--CO-LITTLETON

Address: 20 WEST DRY CREEK CIRCLE STE 100

City, State & Zip: LITTLETON, CO 80120

Phone: 303-798-1009
3. Name: PEAK TO PEAK FAMILY PRACTICE

Address: 7768 VANCE DRIVE STE B

City, State & Zip: ARVADA, CO 80003

Phone: 303-427-7700
4. Name: CENTER FOR OCCUPATIONAL SAFETY AND HEALTH

Address: 605 BANNOCK STREET PAVILION H 4TH FLOOR

City, State & Zip: DENVER, CO 80204

Phone: 303-436-7155
5. Name: SCL PHYSICIANS--WHEAT RIDGE

Address: 9830 W I-70 FRONTAGE ROAD SOUTH

City, State & Zip: WHEAT RIDGE, CO 80033

Phone: 303-467-4100
In the event of a life- or limb-threatening emergency, the injured employee will be sent to the nearest emergency medical facility. One of the medical providers designated above must provide all follow-up care.

If an unauthorized medical provider treats an employee, the employee will be responsible for payment for said treatment.
I have read and am fully aware of the organization’s policy regarding medical treatment for work-related injuries and illnesses. I further understand that I must immediately report any work-related injury to my supervisor. All employees must sign below, acknowledging this policy. *
Employee's Name
Employee's signature*

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