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(806) 687-0201
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ADDRESS

3330 70th Street, Suite 204
Lubbock, Texas 79416

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EMPLOYEE ACKNOWLEDGMENT OF
WORKERS' COMPENSATION NETWORK

I have received information that tells me how to get health care under my employer’s workers’
compensation insurance.

If I am hurt on the job and live in a service are described in this information, I understand that:

  1. I must choose a treating doctor from the list of doctors in the network. Or, I may ask my primary care physician to agree to serve as my treating doctor. If I select my primary care physician as my treating doctor, I will call my company’s worker’ compensation insurance company and notify them of my choice.

  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 anywhere.

  3. The insurance carrier will pay the treating doctor and other network providers.

  4. I might have to pay the bill if I get health care from someone other than a network doctor without network approval.

  5. Knowingly making a false worker’ compensation claim may lead to a criminal investigation that could result in criminal penalties such as fines and imprisonment.

Name of Employer:  Double T Cable Services, Inc.

Name of Network: Coventry

Network services areas are subject to change.


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