Fillable Check One: Initial Employee Notice I have the (National American Insurance Company)

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Check One: Initial Employee Notice I have the (National American Insurance Company)

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Texas CorCare
®
Acknowledgement Form – English v.2014-01
EMPLOYEE ACKNOWLEDGEMENT FORM
Effective: _________________________________
Check One: Initial Employee Notice
Injury Notice -- Date of Injury____________________
I have the information that tells me how to get health care under workers compensation
insurance. If I am hurt on the job and I live in the service area described in this information, I
know that:
• I must choose a treating doctor from the list of doctors who contracted with CorCare
®
or I
may ask my HMO primary care physician to agree to serve as my treating doctor. If I select
my HMO primary care physician to agree to be my treating doctor, I will call CorVel at (866)
353-9768 to notify them of my choice.
• I realize that, except for emergencies, I must get all health care, including referrals to
specialists, from my CorCare treating doctor for my compensable work injury. If I need
emergency care, I may go anywhere.
• The insurance carrier will pay the treating doctor and other network providers and will not
bill me for a compensable injury.
• Except for emergencies, if I get health care that is not approved by CorCare
®
, from a doctor
who is not with CorCare
®
, the insurance carrier may not pay for that care. I may have to pay
for that care.
________________________________________________________
Employee's Signature Date
________________________________________________________
Employee's Printed Name
________________________________________________________
Employee's Address (Where I live)
________________________________________________________
City State Zip
________________________________________________________
Employers Name
CorVel Corporation/Texas CorCare
®
________________________
Network's Name -- Return form to employer, carrier or third party administrator.
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Check One: Initial Employee Notice I have the (National American Insurance Company)

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Completed 29 July 2021

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