Employee Acknowledgement of the Alliance Direct Contracting Program & Leave Benefit Election

Employee Acknowledgement of the Alliance Direct Contracting Program
I have received information that tells me how to get health care under my employer’s workers’ compensation coverage. If I am hurt on the job and live in a service area described in this information, I understand that:

1. I must choose a treating doctor from the Alliance list of doctors designated as treating doctors.

2. I must go to my treating doctor for all health care for my injury. If I need a specialist, my treating doctor will refer me. If I need emergency care, I may go to any licensed medical professional within the United States.

3. Even though my treating doctor should refer me to a specialist of providers contracted with the Alliance, I understand that I need to verify that the referral doctor is a member of the Alliance provider panel.

4. The Texas Association of School Boards Risk Management Fund will pay the treating doctor and other Alliance providers for all health care related to my compensable injury.

5. I understand that my medical and/or income benefits may be disputed if I receive health care from a provider other than an Alliance provider without prior approval from the Fund.

6. Making a false or fraudulent workers’ compensation claim is a crime that may result in fines and or imprisonment.

7. If I want to change doctors after my first choice, I can do so within the first 60 days of starting treatment, and I can only choose from the Alliance list of providers. A third choice requires approval from my adjuster.
I understand and agree to the above*

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Signature
Date*

MonthDayYear
Date
Printed Name
I live at*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Employer: Kennedale Independent School District Name of Direct Contracting Program: Political Subdivision Workers’ Compensation Alliance (the Alliance)

Direct contracting service areas are subject to change. To locate a treating doctor within your area, visit the PSWCA web site at pswca.org or call your adjuster at 800.482.7276.
TASB Risk Management Fund © 2019 Texas Association of School Boards, Inc. All rights reserved.
EL E C T LE A V E BE N E F I T W I T H W O R K E R S’ COMP E N S AT I O N (NO OF F S E T)
Name*
Employee number
Position*
Department/Campus*
This employee is absent from duty because of a job-related illness or injury beginning on (date of first absence attributable to illness or injury). If eligible, workers’ compensation insurance may begin paying a percentage of the employee’s current wages on the eighth day of absence from duty if an extended absence is required.

I am absent from duty because of a job-related illness or injury. I understand that I am not eligible for workers’ compensation weekly income benefits until my absence exceeds seven calendar days. I also understand that the district will continue to pay its contribution toward the cost of my group health insurance coverage (if applicable) as long as I am on paid leave and/or family and medical leave (FMLA I further understand that I will be responsible for paying all health insurance premiums if I am on unpaid leave that is not FMLA leave.
I choose to use only a certain number of days available paid leave at this time (please enter the number below)I choose to use all available paid leave. I understand that I will not receive workers' compensation weekly income benefits until I have exhausted all of my paid leave or to the extent that paid leave does not equal my pre-illness or injury wage.I choose not to use any available paid leave at this time. I understand that I will not receive any regular salary payments from Kennedale ISD while receiving weekly income benefits under workers' compensation. No available paid leave will be deducted from my leave balance. I further understand that by selecting this option I will only receive worker's compensation benefits for any absences resulting from my work-related illness or injury, unless and until I communicate to the district a change in my decision
If you selected the first option above, please indicate how many days of paid leave you would like to use here
(please enter a number)
Employee signature*

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Email*
example@example.com
Date*

MonthDayYear
Date
Should be Empty:

Employee Acknowledgement of the Alliance Direct Contracting Program

EL E C T LE A V E BE N E F I T W I T H W O R K E R S’ COMP E N S AT I O N (NO OF F S E T)