Information
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Name of Document:
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Document No.
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Conducted on
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Prepared by:
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Jason Corbin
- Michael Wright
- Lee Ratliff
- James Brown
- Scott Taylor
- Anthony Beverly
- Hugh French
- Chuck Ayers
- James Shifflett
- Joe Bailey
- Michael Dwyer
- Christopher Cole
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Location (Drop Pin for GPS & Address):
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Employee Requesting / Requiring Medical Treatment (Full Legal Name):
Section 65.2-603 of the Virginia Workers’ Compensation Act requires employers to provide a panel of at least three Treatment Centers. You must select a Treatment Center from this panel to treat your work-related injury. If you do not use one of these Treatment Centers for your work-related injury, you may be responsible for the cost of medical care and you may jeopardize your entitlement to workers’ compensation as outlined in the Act. Please select a Treatment Center from this panel, complete and sign the form and return it to the Safety Manager, Human Resources, or your supervisor.
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Physician 1: Spotsylvania Emergi-Center, 992 Bragg Road, Fredericksburg,VA 22407, (540) 786-7637
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Physician 2: Nextcare Urgent Care, 15 S. Gateway Dr.,Ste 101, Fredericksburg, VA 22406, (540) 368-5603 or 330 White Oak Rd., Fredericksburg, VA 22405. (540) 373-2424
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Physician 3: Patient First, 3031 Plank Rd., Fredericksburg, VA 22401, (540) 736-5043
I have been presented with a panel of at least three Treatment Centers and have selected one of the above to provide me with medical care for my work-related injury:
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Employee Signature:
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Location of Injury (Please drop pin to mark location):
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Date Reported to Safety Manager:
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Date of Injury:
