Designation of Medical Providers

Transcription

1 Designation of Medical Providers Brakes Plus, Inc. hereby designates the following medical providers to provide treatment for your work related injuries: Please select a provider from the following list, write the name, address and phone number of the provider you have chosen to treat with and sign and date below where indicated. Provider Name: Provider Address: Provider City State Zip: Provider Phone: Printed Name of Employee Signed Name of Employee Date of Signature The name and contact information of our authorized representative is: Krysti Giese - HR Director 6911 S Yosemite St, Centennial, CO x244 kgiese@brakesplus.com The name and address of our insurer/third party administrator is: Travelers Insurance Company PO Box Denver, CO Phone: Fax: If you have any questions, please contact our authorized representative or insurer/third party administrator.

2 Providers marked with a ** or * are Preferred Providers with Travelers Insurance. This means they have better communication with the docs. You are not required to choose one of these. You may choose any of the providers listed for your store. If you would prefer to go to another provider listed for a different store because they are closer to your home, that is acceptable. As long as the provider is on this list, they are approved for you to choose from. Colorado law requires an employer to provide 4 Occupational Medicine Providers for an injured worker to choose from. This list shows the closest Designated Providers to your stores. In most cases these are less than 10 miles from your store. In rural areas, availability is much less, therefore there may be two different providers at the same location, or one or more providers may be significantly more than 10 miles away. 100 * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , East - West Health Centers 8200 E Belleview Ave Ste 202 C Greenwood Village, CO P * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , East - West Health Centers 8200 E Belleview Ave Ste 202 C Greenwood Village, CO P * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO P * Concentra Medical Center 20 W Dry Creek Cir Ste 100 Littleton, CO P * Healthone 125 E Hampden Ave Englewood, CO P Lutheran Southwest Urgent Care W Coal Mine Ave Ste 110 Littleton, CO P * Concentra Medical Center E Iliff Ave Aurora, CO P * Healthone 1444 S Potomac St Ste 210 Aurora, CO P , * Nextcare Urgent Care E Hampden Ave Aurora, CO P * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO P * Concentra Medical Center 20 W Dry Creek Cir Ste 100 Littleton, CO P Exempla Healthcare W Alameda Pkwy Ste A Lakewood, CO P * Healthone 125 E Hampden Ave Englewood, CO P Lutheran Southwest Urgent Care W Coal Mine Ave Ste 110 Littleton, CO P * Arbor Occupational Medicine 290 Nickel St Ste 200 Broomfield, CO P CCOM/North Denver 8510 Bryant St Ste 360 Westminster, CO P * Concentra Medical Center 7401 Church Ranch Rd Bldg 2 Ste 202 Westminster, CO P Exempla Northwest Medical Center 4750 W 120th Ave Ste 100 Westminster, CO P * Concentra Medical Center 500 E 84th Ave Ste B14 Thornton, CO P * Healthone Pecos St Ste 300 Westminster, CO P * Healthone 9195 Grant St Ste 100 Denver, CO P , * Occ Med Colorado 550 Thornton Pkwy Ste 110 Thornton, CO P CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P ,

3 107 * Healthone E Arapahoe Rd Ste 160 Centennial, CO P University Medicine Anschutz Medical 1635 Aurora CT Ste 5600 Aurora, CO P * Concentra Medical Center 2490 W 26th Ave Denver, CO P Exempla Healthcare 9830 I-70 Frontage Rd S Wheat Ridge, CO P * Healthone 1515 Wazee St Ste D Denver, CO P , Rocky Mountain Urgent Care 6080 W 92nd Ave Westminster, CO P , * Concentra Medical Center 500 E 84th Ave Ste B14 Thornton, CO P Exempla Thornton Medical Center 1181 E 120th Ave Unit A Thornton, CO P * Healthone 9195 Grant St Ste 100 Denver, CO P , * Occ Med Colorado 550 Thornton Pkwy Ste 110 Thornton, CO P CO Rehab and Occupational 401 W Hampden Pl Ste 220 Englewood, CO P * Concentra Medical Center 1212 S Broadway Ste 100 Denver, CO P , * Healthone 125 E Hampden Ave Englewood, CO P Rocky Mountain Medical Group 730 W Hampden Ave Ste 200 Englewood, CO P * Concentra Medical Center 605 Parfet St Ste 103 Lakewood, CO P , Exempla Healthcare W Alameda Pkwy Ste A Lakewood, CO P * Healthone 120 Bryant St Denver, CO P , Union Medical PC 200 Union Blvd Ste 318 Lakewood, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO P * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO P * Healthone 125 E Hampden Ave Englewood, CO P * Concentra Medical Center 620 S Lemay Ave Fort Collins, CO P , * Occupational Health Services 4674 Snow Mesa Dr Ste 200 Fort Collins, CO P PVMG-Occupational Health Services 1330 Oakridge Dr Fort Collins, CO P Workwell Occupational Medicine 1600 Specht Point Rd Ste 115 Fort Collins, CO P * Banner Occupational Health 1703 E 18th St Ste 4 Loveland, CO P * Concentra Medical Center 620 S Lemay Ave Fort Collins, CO P , * Occupational Health Services 2500 Rocky Mountain Ave Ste 330 Loveland, CO P * Workwell Occupational Medicine 1608 Topaz Dr Loveland, CO P , * Arbor Occupational Medicine 1860 Industrial Cir Ste D Longmont, CO P * Concentra Medical Center 3300 N 28th St Boulder, CO P , Exempla Healthcare 8350 Colorado Blvd Ste 160 Firestone, CO P * Workwell Occupational Medicine 205 S Main St Ste C Longmont, CO P Banner Occupational Health th Avenue CT Greeley, CO P * Occupational Health Services 2500 Rocky Mountain Ave Ste 330 Loveland, CO P PVMG-Occupational Health Services th St Greeley, CO P Workwell Occupational Medicine 2528 W 16th St Greeley, CO P Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO P * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P

4 119 Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO P * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO P * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P * Centura 6011 E Woodmen Rd Ste 100 Colorado Springs, CO P , * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO P Healthquest Medical Inc 1495 Garden of The Gods Rd Ste 102 Colorado Springs, CO P Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P Excel Physical Occupational Therapy 4117 N Elizabeth St Pueblo, CO P Pikes Peak Physical Medicine 509 Colorado Ave Ste C Pueblo, CO P * Pueblo CCOM 4112 Outlook Blvd Ste 255 Pueblo, CO P Total Healthcare 4112 Outlook Blvd Ste 37 Pueblo, CO P Excel Physical Occupational Therapy 4117 N Elizabeth St Pueblo, CO P Pikes Peak Physical Medicine 509 Colorado Ave Ste C Pueblo, CO P * Pueblo CCOM 4112 Outlook Blvd Ste 255 Pueblo, CO P Total Healthcare 4112 Outlook Blvd Ste 37 Pueblo, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO P * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * CCOM South Denver 20 W Dry Creek Cir Ste 300 Littleton, CO P * Concentra Medical Center 7150 S Fulton St Bldg 200 C Englewood, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * Concentra Medical Center 875 S Colorado Blvd Denver, CO P * Healthone 120 Bryant St Denver, CO P , * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * Arbor Occupational Medicine 290 Nickel St Ste 200 Broomfield, CO P Boulder Community Medical Center 1000 W South Boulder Rd Ste 100 Lafayette, CO P , * Concentra Medical Center 7401 Church Ranch Rd Bldg 2 Ste 202 Westminster, CO P

5 128 Exempla Northwest Family & Occ Med Sheridan Blvd Broomfield, CO P * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P * Concentra Medical Center 875 S Colorado Blvd Denver, CO P * Healthone 125 E Hampden Ave Englewood, CO P * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * Centura 6011 E Woodmen Rd Ste 100 Colorado Springs, CO P , * Concentra Medical Center 5320 Mark Dabling Blvd # 100 Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Edge Rehabilitation and Wellness 6985 Tutt Blvd Colorado Springs, CO P Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO P * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Pikes Peak Physical Medicine 2955 Professional Pl Ste 201 Colorado Springs, CO P Broadmoor Medical Clinic 1299 Lake Plaza Dr Colorado Springs, CO P * Concentra Medical Center 2322 S Academy Blvd Colorado Springs, CO P * CSSC at Circle 3030 N Circle Dr Ste 217 Colorado Springs, CO P , Edge Rehabilitation and Wellness 2150 Hollow Brook Dr Ste 100 Colorado Springs, CO P * Concentra Medical Center E 38th Ave Aurora, CO P , Exempla Healthcare 2803 Roslyn St Denver, CO P * Healthone 1444 S Potomac St Ste 210 Aurora, CO P , * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , * Arbor Occupational Medicine 8200 E Belleview Ave Ste 428-C Greenwood Village, CO P CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO P ** Concentra Medical Center E Arapahoe Rd Suite 100 Centennial, CO P , * Healthone E Arapahoe Rd Ste 160 Centennial, CO P * Concentra Medical Center 5855 E Stapleton Dr N Ste A-130 Denver, CO P Exempla Healthcare 2803 Roslyn St Denver, CO P * Healthone 1515 Wazee St Ste D Denver, CO P , * Rocky Mountain Family Medicine E Mississippi Ave Ste 110 Aurora, CO P , CO Rehab and Occupational 2646 Patterson Rd Ste A Grand Junction, CO P Grand Valley Urgent Care 1060 Orchard Ave Ste N Grand Junction, CO P St. Mary`s Occupational Health 2686 Patterson Rd Grand Junction, CO P , WorkPartners 2646 Patterson Rd Ste A Grand Junction, CO P , CO Rehab and Occupational 9399 Crown Crest Blvd Ste 240 Parker, CO P * Concentra Medical Center 9330 S University Blvd Ste 100 Highlands Ranch, CO P * Premier Occupational Medicine Jackson Creek Pkwy Unit 120 Monument, CO P Rocky Mountain Medical Group 4348 Woodlands Blvd Ste 100 Castle Rock, CO P