Dear Health Care Provider:

I am an employee of a railroad.  As a railroad employee, I have specific job duties that I am required to perform which involve a significant amount of physical dexterity.  I can provide you with a document describing those duties.

As a railroad employee, my rights are governed by federal law and not a state workers' compensation act.  Any claim for my injury sustained at work comes under the Federal Employers' Liability Act (FELA).

Under the FELA, I have the right to seek a monetary recovery from the railroad for pain and suffering, loss of a normal life and the value of the impairment to my income producing capacity.  If injured on the job, I may be required to be seen by a company doctor.  However, I am not required to accept their medical treatment.  I have the right to choose my own treating health care providers, which is why I have come to you for medical treatment.

Your medical bills for my treatment will be paid under my union's negotiated health care plan.  Your bill(s) can be sent to my employer railroad or directly to my insurance provider for processing.  You may, also, send my employer railroad medical reports relating to my injury that support your bill(s) and describe the services you provided.  Your sending bills and reports to my employer railroad in no way waives my right to our doctor / patient privilege, which I specifically ask you to respect and enforce.  Lastly, I do not authorize any consultation with railroad personnel, its medical department or their representatives.