Fill - Free fillable NationalAmericanInsura nceCompany TexasHealthCareNetworkAcknowledgment ThisacknowledgmentindicatesthatyouhavebeeninformedofTexaslegislationregardingtheeffectsofparticipationor nonparticipationinaTexas PDF form

NationalAmericanInsura nceCompany

TexasHealthCareNetworkAcknowledgment



ThisacknowledgmentindicatesthatyouhavebeeninformedofTexaslegislationregardingtheeffectsofparticipationor

nonparticipationinaTexasCertifiedHealthCareNetwork.NAICOhas offeredparticipation underyourworker’s

compensationpolicytoprovidehealthcareservicestoyourinjur

edemployeesthroughNationalAmericanInsurance

Company’scontractednetwork,TexasCorCareCertifiedNetwork,CorVelCorporation’scertifiedWorkers’

CompensationHealthCareNetwork,asprovidedinChapter1305oftheTexasInsuranceCodeandintitle28,Chapter10

oftheTexasAdministrativeCode.



WewillprovideyouwithinformationconcerningtheuseofCorVel’sCertifiedWorkers’Co

mpensationHealthCare

Networkandyourrightsandresponsibilitiesasaparticipantinthenetworkprogram.Thisincludesinformation

describingtheservicearea(s)applicabletoyouandyourinjuredemployeesasrequiredinRuleVIK.oftheTexasBasic

ManualofRules,ClassificationsandEx

perienceRatingPlanforWorkers’CompensationandEmployers’Liability

Insurance.InaccordancewithChapter1305TexasInsuranceCodeandTitle28,Chapter10oftheTexasAdministrative

Code,wewillalsoprovideinformationrequiredtobegiventoemployees,includinganemployee’snoticeofnetwork

requirementsandanemployeeacknowledgementform.



Yourpre

miummaybeaffectedbasedonnetworkparticipation.OptingtoparticipateintoaCertifiedTexasHealthCare

Networkwillallowyoutocontinuetoreceivebillreductionsabovethefeeschedule.Optingoutofparticipationina

CertifiedTexasHealthCareNetworkwillleadtoincreasedmedicalbills,whichmayleadtoanincreaseinpremiu

m.

PremiumsmayalsoincreaseifNAICOdeterminethatyouhavefailedtoprovidethenoticeofnetworkrequirementsand

employeeacknowledgementformtoyouremployeesinaccordancewithChapter1305.005(d)and1305.451Texas

InsuranceCodeandTitle28,Chapter10oftheTexasAdministrativeCode.



Pleaseindica

tebelowyourintentionregardingparticipationinaTexasCertifiedHealthcareNetwork:



______ Ielectunderthispolicytoprovideworkers’compensationhealthcareservicestoinjuredemployees

throughNationalAmericanInsuranceCompany’scontractednetwork,TexasCorCareCertifiedNetwork,

CorVelCorporation’scertifiedWorkers’CompensationHealthCareNetwork.



____

__ IdonotwishtoparticipateinaTexas CertifiedHealthcareNetwork.



ThisacknowledgementwillapplytofuturepolicyrenewalswithNationalAmericanInsuranceCompany(NAICO)unless

theemployernotifiesNAICOinwritingofitsdesiretoterminatenetworkparticipation.



Signedby______________________________________________Time________________Date________________

 Signature&Title(MustbesignedbyOwner,OfficerorPartner)



EmployerName______________________________________________



WCPolicyNo.__________________________________________EffectiveDate_____________________________



PleasereturntoNationalAmericanInsuranceCompany

Fax:405‐240‐5438

Mail:P.O.Box38,Chandler,OK74834

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NationalAmericanInsura nceCompany TexasHealthCareNetworkAcknowledgment ThisacknowledgmentindicatesthatyouhavebeeninformedofTexaslegislationregardingtheeffectsofparticipationor nonparticipationinaTexasCertifiedHealthCareNetwork.NAICOhas offeredparticipatio

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