Work-related accident/injury procedures
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1 PLEASANT VALLEY SCHOOL DISTRICT Work-related accident/injury procedures If a co-worker is injured and unable to drive themselves and a family member can not be reached, DO NOT transport them to a doctor or hospital in your personal vehicle. Always call 911 for an ambulance. Procedure to follow when completing an accident/injury report for Workers Compensation for your own work-related accident/injury Supervisor responsibility: 1. Complete the Accident Investigation Form and forward to Deborah Sandt in the District Office. 2. Give SDIC Safety Packet (insurance packet) to injured employee. Make sure they receive a copy of the list of panel doctors. Employee responsibility: 1. Report the work-related accident/injury to supervisor immediately. 2. After getting insurance packet from supervisor follow instructions in packet to report work-related accident/injury to SDIC Employee Instructions for Claims Reporting. Call the 800 number to report your work-related accident/injury. Call the district Workers Compensation Coordinator, Deborah Sandt, ext. 1315, in the District Office, that you have reported your work-related accident/injury. Seek medical treatment with one of the providers listed on your Posted Panel from the list provided in your packet. Give your claim number and SDIC s address to all medical providers. Use the Pharmacy Sheet and temporary pharmacy card to fill scripts issued for treatment of your work-related accident/injury. Complete all documents in the packet as soon as possible. Make sure you complete and sign the Medical and Employee Record Release form and leave it with your health care provider. Sign and return the Employees Rights and Duties to Deborah Sandt, District Office. Notify your Claims Representative at SDIC and the district Workers Compensation Coordinator immediately when you receive a return to work date. Sign and return the Employees Rights and Duties to Deborah Sandt, District Office Failure to complete the above steps following a work-related accident/injury may result in your not being able to collect the Workers Compensation benefits to which you are entitled. Instruction and information regarding reporting work-related injuries are available to district employees through the employee portal on the district web site PV Home Page Staff Employee Portal.
2 KENNETH NEWMAN Assistant to the Superintendent PLEASANT VALLEY SCHOOL DISTRICT District Administration Office 2233 Route 115, Suite 100 Brodheadsville, Pennsylvania Telephone: (570) / Fax: (570) DAVID F. PIPERATO Superintendent of Schools SUSAN H. FAMULARO Business Manager JOSHUA R. KREBS Director of Support Services JOHN T. BURRUS Director of Human Resources Workers' Compensation Information (1) The workers' compensation law provides indemnity benefits (wage loss) and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. (2) Your employer is required to pay benefits when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers' compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid. (3) You should report any injury or work-related illness as soon as possible to your employer and to your Workers Compensation service provider as directed. Your benefits could be delayed or denied if you do not notify your employer immediately. (4) You have the right to request a hearing before a workers' compensation judge if your employer denies your claim. (5) The Bureau of Workers' Compensation cannot provide legal advice. However, you may contact the Bureau of Workers' Compensation for additional general information at: Bureau of Workers' Compensation 1171 South Cameron Street, Room 103 Harrisburg, Pennsylvania Telephone number within Pennsylvania (800) ; Telephone number outside of this Commonwealth (717) ; TTY (800) (for hearing and speech impaired only PA Keyword: workers comp Excellence in Education: A Community Commitment
3 Name Date ACKNOWLEDGEMENT I hereby acknowledge below receipt of the Workers Compensation Information form by my employer Pleasant Valley School District on 9/05/2017. Employee Signature Date Please Print Name
4 PLEASANT VALLEY SCHOOL DISTRICT WHAT TO DO IN CASE OF A WORK-RELATED INJURY EFFECTIVE JULY 1, 2017 THROUGH JUNE 30, 2018 If you suffer a work-related injury, your health and wellbeing are our first concern. If the injury is of a serious nature and requires the assistance of an ambulance or rescue personnel, they should be contacted immediately. If the injury is of a less serious nature, the following procedures must be followed: 1. If you suffer a work-related injury, the first thing you MUST do is report the injury to your supervisor. S/he or a designated person in your building will provide you with an SDIC packet, and your first step is to call (800) ext You must also call Deborah Sandt, Benefits Bookkeeper. 2. If you require a prescription for your work-related injury or disease, do not use your personal health plan prescription card. Please use the Mitchell International First Fill Sheet, which you will receive in the claim package. When you call in your report of injury to SDIC, they will assign you a claim number. Please use this claim number when seeing a panel physician. 3. If you suffer a work-related injury, PLEASANT VALLEY SCHOOL DISTRICT or our insurer will pay reasonable surgical and medical services and supplies, orthopedic appliances and prosthetics, including training in their use when needed. In order to insure that your medical treatment will be paid for by Pleasant Valley School District or our insurer, you must select from one of the health-care providers listed below for your initial care: Pocono Medical Centers (multiple locations) 285 Prospect Street (570) Coordinated Health Systems (multiple locations) 505 Independence Road, Suite A (610) PT must be scheduled thru One Call Care Management (Align) - (866) Lehigh Valley Physicians Group 17 th & Chew, Suite 101 Allentown, PA (610) Area of Specialty: Family Medicine Mountain Valley Orthopedics (multiple locations) 600 Plaza Court, Suite C (570) Area of Specialty: Orthopedics Stroudsburg Eye Specialists 852 North 9 th Street Stroudsburg, PA (570) Area of Specialty: Ophthalmology St Luke s Internal Medicine 1545 N. 9th Street Ste. 100 Stroudsburg, PA (570) Area of Specialty: General Medicine Frank Romascavage, DO Route 209 (570) Area of Specialty: General Medicine PMC Physician Associates 120 Burrus Blvd, Suite 200 (570) Area of Specialty: Family Medicine Mahoning Valley Orthopedics (multiple locations) 246 North 6 th Street Lehighton, PA (610) Area of Specialty: Orthopedics Lehigh Neurology 1250 South Cedar Crest Boulevard, Suite 405 Allentown, PA (610) Area of Specialty: Neurology Neurology Associates of Monroe County 3 Parkinson s Road (570) Area of Specialty: Neurology Moorestown Chiropractic 2627 Hamilton Rd E Stroudsburg, PA (570) Or call Align Networks: (866) Area of Specialty: Chiropractic
5 Palmerton Hospital Physical Therapy: West End Physical Route 209 Kresgeville, PA (610) or- Palmerton Therapy Center 217 Franklin Avenue Palmerton, PA (610) Area of Specialty: Physical Therapy St. Luke s Health Center (multiple locations) 3 Parkinsons Rd. (800) or- St. Luke s Medical Center (multiple locations) 487 E. Moorestown Rd. Wind Gap, PA (484) For Prescriptions: Please use your Mitchell International card at your local pharmacy to bill SDIC directly (Giant, CVS, Rite Aid, Wal-Mart, Walgreens, Acme) For Physical Therapy: NovaCare Rehabilitation For the nearest facility contact: (866) 723-NOVA (central scheduling) One Call Care Management (Align): (866) Area of Specialty: Chiropractic/ Physical Therapy Coordinated Health Systems must schedule thru One Call Care Management (Align) (866) For MRI/EMG/X-Ray/CT Scan One Call Care Management For the nearest facility contact: (800) (central scheduling) Dental One Call Care Management: (888) For Durable Medical Equipment: One Call Care Management (800) Equipment: wheelchairs, walkers, crutches, TENs units, orthotics & prosthetics, etc. 4. Please call in advance for an appointment if you need treatment. You must continue to treat with one of these providers for ninety (90 days) from the date of your first visit. 5. If the ninety (90) day period passes and you still need treatment you may choose to continue with the health care provider on this list, or you may choose another provider. You must notify Pleasant Valley School District Representative, Deborah Sandt, Benefits Bookkeeper of this action within five (5) days of your first visit to the health care provider of your choice. Your bills will be paid if you have provided proper notice and if your provider files reports as required. (These reports must be filed within ten (10) days after your first visit and at least once a month for as long as treatment continues.) 6. If one of the health care providers listed above refers you to a specialist, the Pleasant Valley School District or our insurer will pay for these services as provided by law. All workers compensation claims will be processed on behalf of the School District by: SCHOOL DISTRICTS INSURANCE CONSORTIUM P.O. BOX 1249 NORTH WALES, PA Phone: (800) ACKNOWLEDGMENT: I have been informed of and understand my rights and duties as specified herein. Signature: Date: Please Print Name: * At time of distribution, this information is accurate to the best of our knowledge. This panel is subject to change based on information received from the medical provider.
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