Please complete and return this form to the ICA with the applicable documentation attached. Name of Self-insured Employer: 1.The name, address, telephone number, fax number and email address for each medicalprovider included in the arrangement; 2.A description of services provided and how employees are informed of the servicesprovided (e.g. bulletin notifications, payroll stuffers, etc.-Samples may be provided); 3.The effective date for services provided. In lieu of providing a detailed statement of the arrangements, a self-insured employer may provide a copy of the applicable hospital or medical agreement for each provider. If the original agreement has been renewed, then a copy of the renewal agreement showing the effective date of renewal and terms of renewal must be provided along with the original agreement. Signature of Authorized Signor Title Date 1 All self-insured employers may require that an injured employee report to a specific medical provider for a first time evaluation or an independent medical examination. This is not considered to be direct medical care. Direct medical care occurs when a self-insured employer directs an injured employee to a specific medical provider for treatment of the injury/illness. do not direct medical care for injured workers1. American LegalNet, Inc. www.FormsWorkFlow.com