In accordance with Subpart 325-8 of Title 12 NYCRR, all self-insured employers who have contracted with a preferred provider organization (PPO) for the treatment of workers' compensation injuries and illnesses shall report to the Chair pertinent information with respect to the employer and the preferred provider organization with which it has contracted.
Self-insurers who contract with a PPO are encouraged to use registration form to report the following information directly to the Workers' Compensation Board:
- Name of employer (full legal name as well as DBA or AKA)
- Address of employer
- Name of certified PPO (full legal name as well as DBA or AKA)
- Address of PPO
- Union participation in PPO arrangement
- Effective date of the program
- Name and phone number for employer contact person
Employers which are members of group self-insurance plans must be listed individually, but the contact person may be the program administrator for the group.
Self-insurers are encouraged to report on the registration form the above-referenced information.
Subpart 325-8 of Title 12 NYCRR also requires that, where there is a duty to collectively bargain, an employer must engage in such bargaining with respect to PPO participation and must file with the Board a notarized affirmation signed by the collective bargaining agent(s) confirming that the requisite negotiation of the selection of a PPO has taken place and that the particular union and individual agent(s) which have agreed to such PPO are the recognized or certified exclusive bargaining representatives of the covered employees.
All requested information and notarized affirmations shall be filed with the Workers' Compensation Board within ten days of the effective date of PPO participation.
Notarized affirmations may be delivered by mail, personal delivery or fax to:
Research and Data Analysis Bureau
Workers' Compensation Board
328 State Street
Schenectady NY 12305
Please note that PPO participation will be jeopardized by failure to file the requisite information and notarized affirmations.
Any questions or concerns related to this matter may be directed to (877) 632-4996.
PPO Self-Insured Employer Registration Form