Employee Acknowledgement Form
{"Image DocumentName": "Employee Acknowledgement Form", "Image ImageDescription": "Carrier and employer may use a form that complies with this section or a sample form available from TDI. Form must include: Statement of employee\u2019s responsibility to obtain network services. If employee is injured and lives in service area, then the employee must: Must select a treating doctor. May ask HMO PCP to be treating doctor. Must obtain all services from network providers except emergency care. Employer is required to deliver the notice of employee responsibilities and network requirements and obtain a signed acknowledgement form from each employee: When the employer elects a network plan. Within 3 days after the date a new employee is hired. Upon learning that an injury has occurred. The employer must also post the notice in the workplace. An employee who refuses to sign the acknowledgement form is still subject to network requirements.", "Image XResolution": "37", "Image YResolution": "37", "Image ResolutionUnit": "Pixels/Centimeter", "Image Software": "SlidePlayer", "Image YCbCrPositioning": "Centered"}