WORKER S COMP - - Quick & Dirty

Transcription

1 WORKER S COMP - - Quick & Dirty Make Copies of all forms before starting this process. (DO NOT USE ORIGINALS) Step 1 Employee has accident. A. Complete Attachment A Employee Injuries Form B. Complete Attachment I Accident/Incident/Injury Report within 2 hours of incident C. Scan or fax Accident/Incident/Injury Report to: 1. Staff/Volunteer Accident/Illness/Incident Report fax cover sheet 2. Tamara LeSage tlesage@fragahs.com or Fax or James Anderson james@fratn.com or Fax D. On Attachment A #3 if employee does not want to seek medical attention STOP HERE Step 2 Employee needs immediate medical attention A. Go to #4 on the Employee Injuries Form and follow instructions B. Complete Attachment B Georgia Employer s First Report of Injury C. Follow Instructions for Reporting-A-Claim Online by going to D. Call HR Coordinator to get Authorization for Medical Treatment for a Post-Accident Drug Screen to be done. Send Authorization with employee if going to doctor office on panel. If going to hospital, drug screen will need to be done later at an approved vendor. E. Choose Medical Facility from Panel and complete: 1. Attachment D Provider Referral and Treatment form 2. Attachment F Release of Medical Information form 3. Attachment M Pharmacy Card 4. Attachment G Fitness for Duty F. Make copies of all of the forms above after completion and give original to injured employee to take to medical facility with drug screen kit. G. Continue to complete Attachment A Employee Injuries H. Send copies of all paperwork to: 1. HR Coordinator Fax # (706) or (706) or scan to tlesage@fragahs.com. 2. Payroll Office Fax# (423) or scan to cbaker@fratn.com I. Tell injured employee after seeking medical attention to return all paperwork received at facility to supervisor. Supervisor must fax or scan to: 1. HR Coordinator Fax # (706) or (706) or scan to tlesage@fragahs.com. 2. Payroll Office Fax# (423) or scan to cbaker@fratn.com Step 3 Monitor injured employee s progress and keep the HR Coordinator advised of status. A. Attachment J Employee Contact Sheet needs to be completed for all injured employees out of work for more than one (1) day O:\HR\PERSFRMS\Workers Comp\2011 Changes\WC Quick & Dirty Rev docx Rev 10/16

2 Revised 09/23/14 EMPLOYEE INJURIES If You Are Injured, Follow These Steps!!! Attachment A If the injury is life-threatening, call 911 or immediately seek medical care from the nearest qualified medical provider. Otherwise, follow this process and check off as you complete each item. 1. Tell your immediate supervisor or other appropriate supervisor about the injury. 2. Complete the Accident/Incident/Injury Report (Attachment H and I) if you have had any type of accident, incident, injury or exposure. If the situation involving an injury and treatment beyond simple first aid is needed, be sure to also immediately call the claim in to the worker s comp insurance carrier and complete the necessary worker s comp paperwork in addition to completing this form. (Refer to steps 4 through 8) 3. If you do not need to see a medical care-giver or anticipate that you will need to, the process ends here. If you need to see one in the future related to this injury, you will need to proceed to the next step at the time it becomes necessary. 4. Please complete the First report of injury that is appropriate for the state the employee works in (Attachment B or C) for the Worker Comp Insurance Carrier to explain the details of the injury. After this form has been completed, the supervisor will need to report the claim online at When reporting an injury, please give Pam Wright -- (423) as the agency contact information. In the event of a catastrophic or fatality claim, please call United Heartland immediately at (800) Choose a care-giver from the approved Worker s Compensation Physicians and Provider Panel that is appropriate for the state/site the employee works in. (Please note: TN employees must complete the Physicians and Provider Panel after selecting a medical provider). Complete the Provider Referral and Treatment Form that is appropriate for the state the employee works in (Attachment D or E) for Work-Related Injuries, the Release of Medical Information Form (Attachment F), Temporary Pharmacy Card (Attachment M) and the top portion of the Fitness for Duty Certification (Attachment G). Take these forms, along with a job description or job summary sheet, to the chosen medical care-giver. 6. Please Note: Post accident/injury drug tests are automatically required when an employee has caused, contributed to, or been involved in an on the job injury that results in a loss of work time or requires the services of a health care professional. (See Personnel Policies and Procedures ) 7. Fax the completed accident forms to the places/persons designated at the Program and/or Agency Payroll Office. 8. After you have seen the medical care-giver: A. You must return forms indicated on the Provider Referral and Treatment Form, including a Return to Work or Fitness for Duty Form to your supervisor. B. If you are sent a packet of information to complete from our Worker s Comp carrier, do so immediately and give a copy to your supervisor. C. Fax to the Program and/or Agency Payroll Office, any forms or documents that the Doctor s office or Worker s Comp. carrier gave you. Physician s Recommendations 1. If the care-giver allows you to return to work immediately, you should do so. 2. If the care-giver releases you to modified duty, you should discuss that with your supervisor. 3. If the care-giver indicates you are unable to work at all, you should immediately call your supervisor with detailed information concerning your situation. For any treatment beyond the initial care-giver visit, you or the treating medical care-giver must call the Worker s Comp. Insurance Claims Adjustor for authorization. The Agency Payroll Office can supply you with the number of the Claims Adjustor assigned to your case. Every time you have an additional visit or contact with your physician, you must give a copy of any document that is given to you to your immediate supervisor and that info should be ed to the Payroll Office. If you have any questions you want to ask the Worker s Comp Company, please contact them at (800) Also, you may call an Agency Director, Administrator, or the Payroll Office at any time. If you have to be out, remember you must use leave in accordance with our Personnel Policies and Procedures, and you must notify your supervisor.

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4 Attachment D FAMILY RESOURCE AGENCY, INC. PROVIDER REFERRAL AND TREATMENT FORM FOR WORK-RELATED INJURIES Section 1 to be completed by Injured Employee and Supervisor Dear Provider: Date: (Employee should print name of provider chosen from panel) In accordance with the worker s compensation laws of this state, (Print Name of Employee) (Employee Signature) has chosen you from our panel of Providers and is being referred to you for the purpose of care. This form gives the provider permission for the initial treatment of the injured employee; any type of follow-up treatment must be approved by our Worker Comp Insurance Company: United Heartland Type of Injury/Illness (Describe in detail) To assist our employee in receiving prompt and appropriate medical attention, insurance benefits, and return him/her to work as soon as is possible (if not immediately) please complete this form. Return this form and other appropriate documents to the injured employee so they may be returned to us. Or fax the documents directly to us Attn: HR Coordinator (706) or (706) Work Site Phone# Supervisor s Signature Section 2 to be completed by Health Care Provider Health Care Provider please initial the following as applicable: I have received a copy of the Release of Medical Information Form. I have completed the Post Accident Drug testing. I understand that the Family Resource Agency typically makes modified duty work available to employees injured on the job. I have seen a copy of the employee s job description or job summary sheet so that I am aware of his/her usual duties. I have listed below any prescribed drugs that may effect the employee s ability to safely operate a motor vehicle or be in charge of children (if either is applicable) and noted the length of time the employee is to take the medication. HEALTH CARE PROVIDER PLEASE RETURN THE FOLLOWING WITH THE EMPLOYEE OR FAX IT TO THE ABOVE LISTED FAX NUMBER: 1. This Form. 2. The Attending Physician s Report. 3. The Return to Work/Fitness for Duty Form (employee must have to return to work). 4. Prescriptions if necessary. Please send all bills and doctor s notes to the following address: Family Resource Agency Phone: (423) or (423) Attn: Worker s Comp Department Fax: (423) or (423) Michigan Ave. NE Cleveland, TN Revised 11/11/14

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6 Fitness-for-Duty Certification Attachment G Employee Please complete information below: Employee/Patient s Name: Job Title: DUTIES Admin OPS Prog Coor & Spec Family Svc Spec Circle the box that corresponds to the employee s job. Cross out sections that do not apply. General Office, Computer work, meetings, some travel in area and away. Walking, sitting, some stooping, usually no heavy lifting. Coor: General office/computer work. All: Walking, sitting, stooping, lifting (up to 50#), daily travel, light building maintenance/ construction duties, drive bus for maintenance repairs. Center Managers Teachers/Asst Tchrs Fd Svc Mgrs, Cooks Food Svc Asst General office duties. Some lifting (up to 50#), walking, sitting, stooping. Occasional classroom duties. Birth to 4 year olds. Walking, sitting (in chair/on floor), playing with children inside/ out, lifting (up to 50#). Minor cleaning (stacking chairs, sweeping/vacuuming, wiping off tables, etc.). Meal planning, ordering supplies, cooking, general cleaning of classrooms and offices. Lifting (up to 50#) and stocking supplies. Computer work major portion of job. Walking, sitting, traveling to homes, offices, etc. Usually no heavy lifting. Drives vehicles to centers to deliver meals to classrooms. Heavy lifting (up to 50#), walking, stooping, sitting. Assists with center operations and building maintenance. Physician Please complete one item below: 1. The employee IS able to return to work with NO restrictions as of: Date: 2. The employee IS able to return to work WITH restrictions listed below (please write legibly) as of (specify date): 3. The employee is NOT able to return to work at this time with either modified duties or restrictions. Please indicate possible time frame for return to work: Time frame: Name of Physician/Practitioner Signature of Physician/Practitioner Type of Practice (field of Specialty, if any) Date Rev 09/13

7 Attachment M To the Injured Worker: On your first visit, please give this notice to any pharmacy listed on the back side to speed processing your approved workers compensation prescriptions (based on the guidelines established by your employer). Questions or need assistance locating a participating retail network pharmacy? Call the Express Scripts Patient Care Contact Center at Atencion Trabajador Lesionado: Este formulario de identificación para servicios temporales de prescripción de recetas por compensación del trabajador DEBERÁ SER PRESENTADO a su farmacéutico al surtir su(s) receta(s) inicial(es). Si tiene cualquier duda o necesita localizar una farmacia participante, por favor contacte al área de Atención a Clientes de Express Scripts, en el teléfono To the Pharmacist: Express Scripts administers this workers compensation prescription program. Please follow the steps below to submit a claim. Standard claim limitations include Quantity exceeding 150 pills Day supply exceeding 14 days. Dollar amount exceeding $150 This form is valid for up to 30 days from DOI. Only specific medications allowed If there are issues adjudicating first fill please call Express Scripts at KQSA Thank you for using a participating retail network pharmacy. Even though there is no direct cost to you, it s important that we all do our part to help control the rising cost of healthcare. Please see other side for a list of participating retail network pharmacies. To the Supervisor: Please fill in the information requested for the injured worker. Pharmacy Processing Steps Step 1: Enter bin number Step 2: Enter processor control A4 Step 3: Enter the group number as it appears above Step 4: Enter the injured worker s nine-digit ID number Step 5: Enter the injured worker s first and last name Step 6: Enter the injured worker s date of injury (enter in DOI field in the format YYYYMMDD)

8 A & P Acme Pharmacy Albertson s Albertson s/acme Albertson s/osco Albertson s/sav-on Amerisource Bergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg s Bi-Lo Bi-Mart BJ s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn s Costco Cub CVS D&W Dahl s Dierbergs Discount Drugmart Doc s Drugs Dominicks Drug Emporium Drug Fair Drug Town Drug World Eckerd Econofoods EPIC Pharmacy Network FamilyMeds Farm Fresh Farmer Jack Food City Food Lion Fred s Gemmel Giant Giant Eagle Giant Foods Hannaford Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs Kroger LeaderNet (PSAO) Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network Pharmaceuticals Northeast Pharmacy Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper Publix Quality Markets Raley s Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam s Club Sav-On Save Mart Schnucks Scolari s Sedano Shaw s Shop N Save Shopko ShopRite Snyder Stop & Shop Sun Mart Super Fresh Super Rx Target Texas Oncology Srvs The Pharm Thrifty White Times Tom Thumb Tops Ukrop s United Drugs United Supermarkets Vons Waldbaums Walgreens Wal-Mart Wegmans Weis Winn Dixie NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers compensation claim is not assumed based on the dispensing of medication(s) to a patient.