SAMPLE AFFIRMATION A

NEW YORK STATE
WORKERS' COMPENSATION BOARD


In the Matter of Preferred Provider Organization Participation
By EMPLOYER


                 AFFIRMATION
(Name of Employer Official), attests to the following:

1.          I am the     TITLE                             of          EMPLOYER                   (the Employer") and I file this affirmation in accordance with Article 10-A of the Workers' Compensation Law and12 NYCRR 325-8.2.

[Select and utilize the applicable phrase for paragraph 2]:
2.          I attest that    EMPLOYER   has no unionized employees.
                                                            OR
2.          I attest that    EMPLOYER   has unionized employees; however, such employees are not participating in the Preferred Provider Organization ("PPO") program.

3.          I am aware that no unionized employees may participate in the PPO program until such arrangement is collectively bargained with the recognized or exclusive bargaining representative of the covered employees. Such negotiation and consent must be evidenced in a notarized affirmation signed by the collective bargaining agent, agreeing to the selection of the PPO and agreeing forth the duration of the agreement.

______________________________
Signature of Employer Official

Sworn to before me this ____________
day of _____________, 19__

Notary Signature and Stamp

 

 

SAMPLE AFFIRMATION B

NEW YORK STATE
WORKERS' COMPENSATION BOARD


In the Matter of Preferred Provider Organization Participation by
EMPLOYER
    -and-
UNION


                                            AFFIRMATION
(Name of Union Official) and (Name of Employer Official) attest to the following:

1.         I,      NAME OF UNION OFFICIAL    , am the             UNION POSITION                  of     UNION        ("the Union") which is the recognized or exclusive collective bargaining representative for the members of the Union who are employed by   EMPLOYER   ("the Employer") and who will be covered by this Preferred Provider Organization ("PPO") arrangement. I file this affirmation in accordance with Article 10-A of the Workers' Compensation Law and 12 NYCRR 325-8.2.

2. I, NAME OF EMPLOYER OFFICIAL , am the           TITLE          of the Employer and I file this affirmation in accordance with Article 10-A of the Workers Compensation Law and 12 NYCRR 325-8.2.

3. We affirm that the Employer and the Union engaged in negotiations with respect to the selection of a certified PPO network and have agreed to have CERTIFIED PPO NETWORK as the exclusive source for all initial treatment of work-related injuries and illnesses suffered by members of the Union.

4. We affirm that the duration of this PPO agreement is from ____________ to ____________.  Any subsequent agreements will be made subject to the same prior review and approval process by the Employer and the Union.

___________________________
Signature of Union Official

___________________________
Signature of Employer

Sworn to before me this _____
day of _______, 19__.

Notary Signature and Stamp

 

 

Return to Supplement No. 2 to Circular Letter No. 18 (1997)