DUE: TO PREP 24 HOURS OF INCIDENT
WORKERS’ COMPENSATION
PIEDMONT REGIONAL EDUCATION PROGRAM
PANEL OF PHYSICIANS
MedExpress
1420 South Main Street
Culpeper, VA 22701
540-825-2202
260 Pantops Center
Charlottesville, VA 22911
- OR –
1149 Seminole Trail
Charlottesville, VA 22901
434-244-3027
Karen Poehailos, MD
First Med
125 Riverbend Drive, Ste 3
Charlottesville, VA 22911
434-984-4200
Multiple Physicians
Culpeper Family Practice
1200 Sunset Lane #2210
Culpeper, VA 22701
540-825-6100
434-978-3998
Multiple Physicians
Rappahannock Family Physicians
540-374-5200
120 Executive Center Parkway
Fredericksburg, VA 22401
The closest emergency facility may be used in an emergency situation. Once emergency treatment
is completed, a panel physician must be chosen for follow up care.
_______________________________________________________________________________________
PRESCRIPTION DRUG INFORMATION:
Employee is responsible for purchasing any initial medication(s) prescribed by the physician for the workers’ compensation injury. Please
submit the receipt(s) for reimbursement to:
Joanne Tyler
Piedmont Regional Education Program
225 Lambs Lane
Charlottesville, VA 22901
You should receive a letter in the mail regarding Integrated Prescriptions Solutions (IPS). IPS is a pharmacy benefit management program
that will allow the pharmacy to bill related prescriptions on-line. This program will allow you to get your workers’ compensation prescriptions
without out-of-pocket expenses.
______
I WILL select a doctor, if needed, from the list of designated physicians provided and approved by my employer. I choose
Dr. ______________________________as my treating physician in my workers’ compensation claim.
______
I DECLINE to select a doctor from the list provided by my employer. I understand that I will have to pay for any medical
treatment or hospitalization and that I shall be denied wages and workers’ compensation for any absence based on a disability
which is not certified by a doctor who is approved by my employer.
________________________________________________________________
Signature of Employee
___________________________________
Date