OFFICE OF RISK MANAGEMENT AND SECURITY SERVICES

AUTHORIZED MEDICAL PANEL

pursuant to regulation 532-1, employees who suffer an injury/illness on the job are directed to receive medical assistance at one of the FOLLOWING approved facilities:

employees will be responsible for any medical charges if they elect to visit a facility other than those designated below:

DOCTORS EXPRESS
BLACK, JERROLD, M.D.
MEYER, JOEL M.D.
WEINSTEIN, RAYMOND, M.D.
BERAME, BELINDA, M.D.
BARNETT, WILLIAM, M.D.
AZEEM, NOMEN, M.D. / 4167 MERCHANT PLAZA
WOODBRIDGE, VA 22192
TEL: 703.878.8800
WWW.DOCTORSEXPRESS.COM
hours:
Mon through FRI: 8 a.m. to 8 p.m.
SAT: 8 a.m. to 7 p.m. SUN: 8 a.m. to 7 p.m.
PATIENT FIRST
Bigbee, John, M.D.
Kori, Umakant, M.D.
Mamedova, Tamara, M.D.
Suri, Rohit, M.D.
Iyer, Akila, M.D.
Jose, Starina, M.D. / 9715 LIBERIA AVENUE
MANASSAS, VA 20110
TEL: 571.229.1797
www.patientfirst.com
hours:
Mon – Sun: 8:00 AM – 10:00 PM
INOVA URGENT CARE
KOKA, NANDINI, M.D.
MARPU, NEELIMA, M.D.
SHAFI, LUTFUNNESSA M.D.
USMAN, ANTONIO M.D.
ZIEGLER, HENRY M.D.
ZIA, JAMAL, M.D / 6201 CENTREVILLE ROAD, SUITE 200
CENTREVILLE, VA 20121
TEL: 703.830.5600
www.inova.org
hours:
Mon –Fri: 9:00 – 8:00 pm
Weekends/Holidays: 10 am – 3:00 pm
PATIENT FIRST
ali, khurram, M.D.
antonio, patrick, d.o.
athwal, amardeep, m.d.
baray, ahmad, m.d.
basharmal, khodaidad, m.d.
iver, aklia, m.d. / 14800 LEE HIGHWAY
GAINESVILLE, VA 20155-1842
TEL: (703) 743-7017
www.patientfirst.com/Locations/Virginia/Gainesville
HOURS:
8:00 AM – 10:00 PM – WEEKDAYS, WEEKENDS & HOLIDAYS
PATIENT FIRST
lY, nGOC, M.D.
TRAN, MINH, DO / 2199 OLD BRIDGE ROAD
LAKE RIDGE, VA 22192
TEL: 703-357-9707
www.patientfirst.com
hours:
Mon – Sun: 8:00 AM – 10:00 PM
PATIENT FIRST
BASHARMAL, KHODAIDAD, M.D. BUI HAN Q., M.D.
DONAGHEY, KEVIN, D.O. FARAG, SHANNON, M.D.
FAROQI, MUSHAHID , M.D. LY, NGOC, M.D.
PHAM, HUNG, D.O. TRAN, MINH, D.O. / 60 PROSPERITY LANE
STAFFORD, VA 22556
TEL: 540.658.2811
www.patientfirst.com
hours:
Mon – Sun: 8:00 AM – 10:00 PM

If an injury occurs and results in a blood/body fluid exposure please contact any of the above facilities.

THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION. ONCE THE EMERGENCY TREATMENT IS COMPLETED, A PANEL PHYSICIAN MUST BE CHOSEN FOR FOLLOW UP CARE.

I AGREE TO SELECT A DOCTOR FROM THE ABOVE PANEL

I DECLINE TO SELECT A DOCTOR FROM THE ABOVE PANEL. I UNDERSTAND THAT I WILL HAVE TO PAY FOR ANY MEDICAL TREATMENT OR DOCTOR BILLS, AND THAT I WILL BE DENIED WORKERS’ COMPENSATION FOR ANY ABSENCE BASED ON DISABILITY WHICH IS NOT CERTIFIED BY AN APPROVED PANEL DOCTOR.

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EMPLOYEE DATE

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EMPLOYER/SUPERVISOR DATE

PHARMACY INFORMATION:

Express Scripts is the pharmacy management provider for PMA Companies. Most major pharmacies participate in the program.

The injured employee is provided with a Temporary Prescription Services Sheet from Express Scripts. Please present the completed form to the pharmacy.

For questions concerning a claim please contact:

PMA COMPANIES

P.O. Box 5231

Janesville, WI 53547

Tel: 1.888.476.2669 Fax: 1-800-432-9762

OFFICE OF RISK MANAGEMENT & SECURITY SERVICES:

Tel: 703.791.7210 or 703.791.7206 FAX NO: 703.791.7404

- 1 - Revised 07/07/2016