Injury Reporting Packet City of Macedonia, Ohio 1-888-627-7586 www.careworks.com
Workplace Injury. Take the Right Steps. Helping Simplify the First Report of Injury (FROI) Process 1 2 3 4 INJURED EMPLOYEE 4-STEP PROCESS Immediately notify your Supervisor and Human Resources at (330) 468-8353. Complete the first two sections of the BWC First Report of Injury form as completely as possible and complete the City form Accident/Injury Report. This Injury Reporting Packet contains a CareWorks I.D. card. Show this card to each medical provider that treats your work-related injury. Then, seek treatment from a CareWorks* network provider. Copies of any form filled out at the Emergency Facility and/or Doctor s Office must be returned to your Department Head immediately. In emergency cases, injured workers should immediately notify their employer and seek treatment at the nearest medical facility. *According to Health Partnership Program (HPP) guidelines, injured workers may seek treatment from any BWC-Certified medical provider. 1.888.627.7586 www.careworks.com
IMPORTANT NOTICE FOR WORKPLACE INJURIES In the event of a work-related injury, please see one of the medical providers recommended by your employer listed below and follow these important steps: 1 Report the accident immediately to your Employer. 2 Select a medical provider from the following list for immediate care.* 3 For additional providers, call CareWorks from 8:00 a.m. 5:00 p.m. at 1-888-627-7586. In the event of a life threatening injury, seek the closest hospital emergency room regardless of physician network affiliation or BWC certification status. PROVIDER LISTINGS FOR WORKERS COMPENSATION OCCUPATIONAL HEALTH MedSource One 8555 Sweet Valley Drive Valley View, Ohio 44125 (216) 328-2240 Hours: 8:00 a.m. - 5:00 p.m., Monday - Friday. City of Macedonia 9691 Valley View Road Macedonia, Ohio 44056 Employer Contact: Human Resources at (330) 468-8353. *Employees may receive treatment from any BWC certified provider.
CITY OF MACEDONIA 9691 Valley View Road Macedonia, OH 44056 ACCIDENT / INJURY REPORT PART A: To be filled out by Employee within 24 hours of workplace accident/injury (unless there are extenuating circumstances) and submitted to Immediate Supervisor. Employee Name: Job Title: Department: Telephone: Work Mobile Home Provide detailed description of how the accident/injury occurred: Where did the accident/injury occur (address/location): What date and time did injury/accident occur? What time did you start your shift on date on injury? What job duties were you performing at time of accident/injury? Names of witnesses/coworkers to accident/injury: What Injury(ies) were sustained? What specific body part injured, please also indicate which side of the body e.g. right or left: Was medical treatment received? Yes No Name of physician: Name of hospital: Did you complete a BWC First Report of Injury form (FROI)? Yes What follow-up treatment is required: No What date are you able to return to work: Are there any work restrictions? Declaration: The above report provides a true, accurate and complete account of the accident / incident. Employee Signature Date
Part B: To be filled out by Immediate Supervisor. Returned completed form to Human Resources. How can this accident / incident be prevented from recurring (i.e. training, equipment, scheduling, etc.)? Causal factors that contributed to accident: (Check ALL that apply) Environment: Weather Conditions Housekeeping Lighting Noise Air Temperature Other Human Factor: Level of experience Level of training Physical capability Health Fatigue Stress Other Task: Ergonomics Condition changes Work process Safe work procedures Other Management: Safety policies Enforcement Supervision Hazard correction Preventive maintenance Other Material/Equipment: Equipment failure Design Guarding Hazardous substances Other Supervisor Name (please print) Date March 2015 2
City of Macedonia 9691 Valley View Road Macedonia, Ohio 44056 Summit County 37705802-0 330 468-8353 330 468-8354 34-6001760
FOR WORKERS COMPENSATION INJURY MANAGEMENT ONLY City of Macedonia BWC Policy # 37705802-0 Employer Contact: Human Resources at (330) 468-8353. Please conduct post-accident drug testing. Attention Provider You are required by Rule 4123-6-028 to report work-related injuries within 24 hours. Attention Employee This card is for information purposes only. This card is not a guarantee of coverage. Send Medical Bills to: CareWorks P.O. Box 182726 Columbus, Ohio 43218-2726 Customer Service: 1-888-627-7586 Injury Reporting Fax: 1-888-711-9284 Prior Authorization Fax: 1-888-627-0074 Email: CWmedical@careworks.com Internet : www.careworks.com For prescription drug information, contact 1-800-OHIOBWC or visit www.bwc.ohio.gov.
KEY INFORMATION Medical Management Information Medical Bill Payment Information Other Important Information FAX medical information to: 1-888-711-9284 (toll-free) MAIL medical information to: CareWorks P.O. Box 182726 Columbus, Ohio 43218-2726 Prior Authorization Fax C9 form to 1-888-627-0074 (toll-free) Mail medical bills to: CareWorks P.O. Box 182726 Columbus, Ohio 43218-2726 Billing Questions Call CareWorks Customer Service, toll-free, at 1-888-627-7586 Prescriptions For questions regarding prescriptions, please contact BWC at 1-800-OHIOBWC or visit www.bwc.ohio.gov. Provider Search and Injury Reporting Visit www.careworksmco.com for online injury reporting and provider searches. 5555 Glendon Court Dublin, Ohio 43016 6000 Lombardo Center, Suite 515 Cleveland, Ohio 44131 1-888-627-7586 www.careworksmco.com