Form AR-N
ARKANSAS WORKERS’ COMPENSATION COMMISSION
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
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Ark. C ode Ann.
§§ 11-9-701, 508, 514
AWCC Rule 33
Revised: 1-1-2001
Updated: 8-1-2006
EMPLOYER’S NOTICE TO EMPLOYEE
NOTICE TO EMPLOYEE - Fill out this form to give to your employer immediately. Employer: Be sure
the employee receives a copy of this form [Ark. Code Ann. § 11-9--514 (c)]
Ark. Code Ann. § 11-9-701. Notice of injury or death.
(a)(1) Unless an injury either renders the employee physically or mentally unable to do so, or is made known to the employer immediately after it occurs,
the employee shall report the injury to the employer on a form prescribed or approved by the Workers’ Compensation Commission and to a
person or at a place specified by the employer, and the employer shall not be responsible for disability, medical, or other benefits prior to receipt
of the employee’s report of injury.
(2) All reporting procedures specified by the employer must be reasonable and shall afford each employee reasonable notice of the reporting
requirements.
(3) The foregoing shall not apply when an employee requires emergency medical treatment outside the employer’s normal business hours; however,
in that event, the employee shall cause a report of the injury to be made to the employer on the employer’s next regular business day.
(b)(1) Failure to give the notice shall not bar any claim:
(A) If the employer had knowledge of the injury or death;
(B) If the employee had no knowledge that the condition or disease arose out of and in the course of the employment; or
(C) If the commission excuses the failure on the grounds that for some satisfactory reason the notice could not be given.
(2) Objection to failure to give notice must be made at or before the first hearing on the claim.
CHOICE/CHANGE OF PHYSICIAN
Rights and responsibilities. Treatment or services furnished or prescribed by any physician other than the ones selected
according to the provisions below, except emergency treatment, shall be at the claimant’s/employee’s expense.
Ark. Code Ann. § 11-9-508. Medical services and supplies.
“(e). . . [T]he injured employee shall have direct access to any optometric or ophthalmologic medical service provider who agrees to provide
services under the rules, terms, and conditions regarding services performed by the managed care entity initially chosen by the employer for the
treatment and management of eye injuries or conditions.”
1. Your employer shall have the right to select the initial primary care physician from among those associated with certified MCOs.
2. You may request a change-of-physician. You should initially request a change from the insurance carrier or employer. Within five business days of
your initial request for a change-of-physician, the insurance carrier or employer should notify you of its decision to grant or deny the change-of-physician.
3. If your request for change of physician is denied you may send a petition to the Clerk of the Arkansas Workers’ Compensation Commission for a one
(1) time only change-of-physician.
4. If your employer has contracted with a certified MCO, you shall be allowed to change physicians by petitioning the commission one (1) time only
for a change-of-physician to a physician who must also either be associated with the certified MCO chosen by your employer or who is your regular
treating physician. (Your “regular treating physician” is one who maintains your medical records and with whom you have a history of regular treatment
before the onset of your compensable injury.) The health care provider to whom you change must agree to refer you to the certified MCO chosen by your
employer for any specialized treatment, including physical therapy, and must agree to comply with all the rules, terms, and conditions regarding services
performed by the MCO initially chosen by your employer.
5. If your employer does not have a contract with a certified MCO, you shall be allowed to change physicians by petitioning the commission one
(1) time only for a change-of-physician to a physician who must either be associated with any certified MCO or who is your regular treating physician.
(See definition above.) The health care provider to whom you change must agree to refer you to a physician associated with any certified MCO for any
specialized treatment, including physical therapy, and must agree to comply with all the rules, terms, and conditions regarding services performed by any
certified MCO.
Back side / Two-sided form
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