COURT COUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.State of New YorkCalendar No.WORKERS' COMPENSATION BOARDJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Notice of Right to Select a Workers' Compensation Board AuthorizedHealth Care ProviderInjured Employee's NameInjured Employee's Social Security No.Date of AccidentEmployer's Name and Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TOTo the Injured Employee: For the treatment of your work-related injury or illness, you may choose any physician, podiatrist, chiropractor, or psychologist (upon referral from an authorized physician) who is Workers' Compensation Board authorized and who is accepting workers' compensation patients.GREETINGS:While you may choose to utilize a network or provider which is recommended by your employer or its workers' compensation insurance carrier or to permit your employer to select a provider on your behalf, you may, at any time, change your health care provider without jeopardizing your workers' compensation claim for benefits.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in room Signature of Injured EmployeeDateSignature of WitnessDateYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply., one of the Justices of theCourt in Witness, Honorableday of, 20 County,Please note: It is not necessary for you to sign this consent form if your employer is (i) participating in a certified preferred provider organization (PPO) under Article 10-A of the Workers' Compensation Law, or (ii) participating in the alternative dispute resolution (ADR) pilot program under section 25(2-c) of the Workers' Compensation Law. In accordance with these statutory programs, except in emergency situations, you must obtain at least initial treatment for any workers' compensation injury or illness from the certified network(s) or providers designated by your employer.(Attorney must sign above and type name below)Attorney(s) forTo the Employer: The employer shall provide the above-named injured employee with a copy of this signed form and shall maintain the original form in the employer's records where it may be inspected by the Workers' Compensation Board at any time. This form shall not be submitted to the Workers' Compensation Board nor shall it be executed prior to the occurrence of this employee's work-related injury or illness.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:The Workers' Compensation Board employs and serves people with disabilities without discrimination.Mobile Tel. No.:www.wcb.state.ny.us ESTE RESUMEN ESTÁ ESCRITO EN ESPAÑOL AL DORSO C-3.1 (3-04)American LegalNet, Inc. www.USCourtForms.comCOUNTY OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .:::::::Index No.Calendar No.Estado de Nueva YorkJUNTA DE COMPENSACIÓN OBRERAJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)Aviso de Aceptación de Uso de Proveedor de Servicios o Red de Salud Recomendado porPatrono o Compañía de SegurosNombre Empleado LesionadoSeguro Social Empleado LesionadoDía de Accidente. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Nombre y Dirección del PatronoTHE PEOPLE OF THE STATE OF NEW YORK TOAl Empleado Lesionado:GREETINGS:Para el tratamiento de su lesión o enfermedad relacionada con su trabajo, usted puede escoger cualquier médico, podiatra, quiropráctico o sicólogo (con referido de un médico autorizado) que esté autorizado por la Junta y que esté aceptando pacientes de la Junta de Compensación Obrera.WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County ofo'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomUsted debe firmar esta forma de consentimiento si decide escoger usar una "Red" o Proveedores que sean recomendados por su patrono o por el seguro ó permitir que su patrono seleccione un proveedor en su nombre. Usted puede, en cualquier momento en el futuro cambiar su proveedor de salud de compensación obrera.Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Firma Empleado LesionadoFechaFechaFirma Testigo, one of the Justices of theCourt in Witness, Honorableday of, 20 County,Nota: No es necesario que usted firme este documento, si su patrono (1) participa en la organización certificada de proveedor preferido (PPO) acuerdo bajo el Artículo 10 A de la ley de Compensación Obrera, o (2) participa en el programa piloto de de resolución de alternativas de disputa (ADR) bajo la sección 25(2-C) de la ley de Compensación Obrera. De acuerdo con estos programas establecidos por ley, excepto en situaciones de emergencia, usted deberá al menos inicialmente, recibir tratamiento por lesiones o enfermedad en el trabajo, de una red certificada o de un proveedor designado por su patrono.(Attorney must sign above and type name below)Attorney(s) forAl Patrono: El patrono deberá proveer al empleado lesionado antes mencionado con una copia de esta forma firmada y deberá conservar el original en los records del empleado, donde pueda ser inspeccionada por la Junta de Compensación Obrera en cualquier momento. Esta forma no deberá ser sometida a la Junta de Compensación Obrera, ni deberá ser procesada con anterioridad a la lesión o enfermedad del empleado.Office and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:La Junta de Compensación Obrera emplea y sirve a personas con impedimentos sin discriminar.Mobile Tel. No.:American LegalNet, Inc. www.USCourtForms.comC-3.1S