Managed Care Employee Acknowledgment
ATTENTION: ALL NSU EMPLOYEES
FROM: OFFICE OF HUMAN RESOURCES
State law mandates that we notify all employees of our workers' compensation managed care
arrangement, and that we receive signed copies from all employees as proof of this notification.
Therefore, we would appreciate your signing and returning this memo as soon as possible.
Nova Southeastern University has agreed to provide workers' compensation coverage for health care
services for work-related injuries/illnesses through a managed care arrangement with FICURMA as
outlined in Section 440.134, Florida Statutes.
As an employee of Nova Southeastern University you must notify your supervisor and the Office of
Human
Resources as any work-related injury. If you need medical treatment, these will be provided
through the managed care network.
Treatment received outside the workers' compensation managed care
arrangement is not compensable unless authorized by the Office of Human
Resources and the carrier before the treatment date.
I acknowledge and understand these conditions and my responsibilities in this plan should I be injured
on the job.
Name: ________________________________________________________________________
(Please print)
Signature: _____________________________________________________________________
Date: _______________________________
Thank you for your cooperation. If you have any questions, please contact the benefits office at
ohrbenefits@nova.edu.
MCA-Managed Care
*MCA*
rev 02.08
