Notice That Claimant Must Arrange for Diagnostic Tests & Examinations through a Network Provider State of New York - Workers' Compensation Board DT-1 Claimants are required to obtain Diagnostic Tests and Examinations through the Carrier's Diagnostic Testing Network(s) identified below. This Notice is supplied to the Claimant and Treating Medical Provider pursuant to Workers' Compensation Law §13-a(7) and 12 NYCRR 325-7. Failure to provide the required notice relieves the Claimant of his/her obligation to use the diagnostic testing network(s). PRINT CARRIER NAME HERE PRINT CARRIER NAME HERE Date of Notice: Check the applicable box below: Notice to the Claimant Claimant: First Name Middle Initial Last Name WCB Case Number: (If Available) Mailing Address: Carrier Case Number: Notice to the Treating Medical Provider Name of Treating Medical Provider: Mailing Address: Authorization No.: Identify the Diagnostic Examination or Test that the Claimant must schedule using the Diagnostic Testing Network (check all applicable boxes): X-Ray All MRI CT EMG/NCS Diagnostic Ultrasound Other: To schedule a diagnostic examination or test, contact the Diagnostic Testing Network listed below: Diagnostic Testing Network Identify the diagnostic testing network name, address, toll-free telephone number and any web address or e-mail contact information below: Diagnostic Testing Network: Mailing Address: Phone Number: ( ) Web Address: Fax Number: ( E-mail Address: ) STATEMENT OF RIGHTS AND OBLIGATIONS - DIAGNOSTIC TESTING NETWORKS (WCL §13-a(7) and 12 NYCRR §325-7) 1. 2. 3. 4. 5. 6. The claimant will receive the name, address and phone number of at least five [5] providers. The providers must be located within a reasonable distance from the claimant's home or work. The network must provide the claimant with all providers if there are fewer than five [5] within a reasonable distance. The test must be scheduled and performed within five [5] business days of the request. If the network asks the carrier to approve the test, it must still be performed within five [5] business days of the request from claimant's doctor. The claimant may select any network provider to perform the test. The claimant may discuss with his or her doctor which provider to choose. The claimant should share this notice with all of his or her doctors. The claimant does not have to use a network provider under these circumstances: a. The provider can't schedule the test within five [5] business days. b. The carrier has challenged (controverted) or will controvert the claim. c. In a medical emergency. d. For x-rays taken during an office visit and used for diagnosis and treatment of: fractures, possible fractures, joint dislocations, tumors, infections, loosening of surgical implants, dislocation of prosthetic joints, spinal instability, or follow-up to surgery. If the carrier doesn't provide the required notice, the carrier must pay for tests outside of the network. On written request, the network will provide the actual test film, data or digital images to the claimant's doctor. These items will be sent to the claimant's doctor with the report or within three [3] business days of receipt of the written request. A doctor may order a second test from the network for the purpose of obtaining an accurate diagnosis as set forth in the Medical Treatment Guidelines if the quality of the test is inadequate. The claimant is entitled to reimbursement for reasonable travel costs to and from the provider. 7. 8. 9. More information on diagnostic testing networks is available in Subject Number 046-480, located on the Board's website under Board Bulletins and Subject Numbers. DT-1 (3-12) THE WORKERS' COMPENSATION BOARD EMPLOYS AND SERVES PEOPLE WITH DISABILITIES WITHOUT DISCRIMINATION American LegalNet, Inc. www.FormsWorkFlow.com www.wcb.ny.gov