TRINITY CHARTER SCHOOLS EMPLOYEE STATEMENT OF INJURY

Transcription

1 EMPLOYEE STATEMENT OF INJURY This form is to be completed in its entirety by the Employee No Later than the End of the Shift Fax this form to Texas Healthcare Foundation (972) Form 1-11/2009 Any person who knowingly and/or with intent to injure, defraud, or deceive their company or other person files a statement of claim containing false, incomplete or misleading information, may be guilty of fraud and subject to criminal and substantial civil penalties. Injured Employee D.O.B. Social Security No. ( as it appears on your Social Security card) Are you a Medicare Beneficiary or ever received Medicare benefits? Yes No If yes, what is your Medicare insurance card number? Do you intend on becoming a Medicare Beneficiary within the next 30 months? Yes No If yes, when? Home Facility Job Title of Time of Day of Time Work Shift Incident / / Incident a.m. p.m. Week Started a.m. p.m. Incident Reported To Reported Time Reported a.m. p.m. Exact location in facility where incident occurred Describe equipment or objects involved Describe what you were doing at the time of the incident Describe fully how the incident occurred Describe the nature of your injury Body part(s) involved Have you had a same or similar injury before? Yes No If yes, give details A ARE YOU REQUESTING MEDICAL TREATMENT YES NO Witnesses - Complete Witness Statement(s) - Form 2 Address City State Zip Code Address City State Zip Code I, (Employee), the undersigned herewith CERTIFY that the foregoing statements and answers on this form are complete and true, and that no information has been omitted, and that I made such statements and answers of my own free will. I understand that my Employer does not carry Workers Compensation insurance, and furthermore, that any payments to me or anyone else for any expenses in connection with this incident is not an admission of liability on the part of my Employer. I authorize direct payment of benefits to medical providers and others rendering services in connection with this incident. I hereby authorize for release to my Employer and Texas Healthcare Foundation any information acquired in the course of examination or treatment for the incident referred to above. Employee Signature: Witness: Translated by (if applicable):

2 WITNESS STATEMENT Form 2-11/2009 Fax to Texas Healthcare Foundation (972) of Witness Home Home Job Title Facility Work of Incident Time of Incident a.m p.m. This Witness Statement Concerns My Knowledge of the Alleged Incident 1. of injured Employee 2. If not an employee, reason for presence at location 3. Are you related to the injured Employee? Yes No If yes, how? 4. How long have you known the Employee? 5. Please explain in detail what you know about the incident (name specific individuals, objects or equipment) 6. Did you actually see the incident? Yes No If no, how did you hear about it? 7. Do you know of any other injury or incident that this employee has had? Yes No If yes, please explain 8. Give the names and addresses of any other persons who might know about the incident 9. Additional comments I CERTIFY that the foregoing statements and answers on this form are complete and true, and that no information has been omitted. Witness: Signature Translated by (if applicable): Verified by: Signature

3 Form 3-11/2009 SUPERVISOR S INCIDENT INVESTIGATION (Information obtained from completed Forms 1 & 2) 1. When an injury occurs immediately contact Texas Healthcare Foundation at (972) or (800) Complete form No Later than the End of the Shift. 3. Immediately fax all completed forms to Texas Healthcare Foundation at (972) D.O.B. Social Security No. Home Address City State Zip Home Facility Job Title of Hire Scheduled Hours/Day Hourly Rate Scheduled Days Per Week Weekly Rate Location (If different from above) Location No. Fax Incident Information of Time of Incident / / Incident a.m. p.m. Reported / / Time Reported a.m. p.m. Was the Incident reported immediately? Yes No To whom was it reported? Exact location/area where the incident occurred Fully describe the incident Describe the injury and body part(s) involved Medical Provider of Clinic/Hospital/Physician If not a designated provider, please complete the following: Code Witnesses Relationship Has a Witness Statement been completed? Yes No Relationship Has a Witness Statement been completed? Yes No I CERTIFY that the foregoing statements and answers on this form are complete and true, and that no information has been omitted. Signature of Supervisor Supervisor Printed X Supervisor Signature

4 MEDICAL TREATMENT AUTHORIZATION Send a copy to designated provider along with Physician s Report of Employee Injury. Retain a copy for your file. Fax to Texas Healthcare Foundation at (972) Form 4-11/2009 (Employee s ) (Social Security Number) To: Designated Provider The above referenced Employee has reported sustaining an occupational injury related to his or her employment. You are authorized to provide medically necessary treatment and/or prescription services for conditions related to the reported occupational injury. Drug/Alcohol Screen Required Yes No If this box is signed and dated, the Employee is required to submit to a drug/alcohol screen which is only for the initial examination and/or emergency treatment of the occupational injury noted below. Please conduct a drug/alcohol screen for your panel of controlled substances and alcohol, in addition to treating the occupational injury. The results of the drug/alcohol screen must be reported only to the Employer. (Authorized Supervisor) Injury description The attached Physician s Report of Employee Injury ( Report ) must be completed by the authorized treating physician. Please provide the Employee with a copy of this Report and attach a copy to your billing document. Your charges for medically necessary services will be paid directly by the Employer. To facilitate prompt payment, submit your billing document and a copy of the Report to: Texas Healthcare Foundation 1278 FM 407, Suite 105 Lewisville, Texas Treatment and billing inquiries should be directed to Texas Healthcare Foundation at (972) or (800) For authorization to release medical records and other information relating to the above Employee s occupational injury, refer to the Medical Records Release Authorization. Supervisor Printed _ X Supervisor Signature

5 PHYSICIAN S REPORT OF EMPLOYEE INJURY Form 5-11/2009 Please be advised that this Employer does not carry workers compensation insurance. If it becomes necessary to refer to another medical provider for treatment or opinion, please furnish such information to us prior to the referral for further authorization. All bills for authorized medical treatment or any inquiries concerning authorization for treatment should be directed to: Texas Healthcare Foundation, Attn: Claims Department, 1278 FM 407, Suite 105, Lewisville, Texas or Fax of Injured Employee 1. of injury first treatment rendered 2. Description of incident 3. Initial complaints 4. Diagnosis 5. Nature, extent, degree, body part(s) of injury 6. Treatment prescribed and prognosis 7. Medication prescribed 8. Probable length of hospital confinement (if applicable) 9. X-ray(s) taken? Yes No Describe procedure(s) and results: 10. Lab test(s) taken? Yes No If Describe procedure(s) and results: 11. Was there any evidence of a prior or pre-existing injury? Yes No If yes, what condition and to what extent may it contribute to incapacity or recovery? 12. In an effort to help employees to more quickly return to work after an occupational injury, a limited duty program is available. The Employee May return to work today without restrictions May return to work today with restrictions as indicated below for days May not return to work until Drug/Alcohol Screen 13. If restrictions are required on or off the job, please indicate below: Required No standing over hours No lifting over lbs. Yes No No work requiring depth perception/driving No stooping/bending/twisting Completed No reaching over shoulder height No walking over hours No use R/L hand/upper extremities No weight-bearing R/L foot Yes No No climbing over hours Must use crutches/splint No pushing/pulling over lbs. No operation of machines/equipment Keep wound clean, dry days No exposure to (specify, e.g. dust, chemical) 14a. Released to restricted duty / / 14b. Released to regular duty / / 15. Will Employee require further medical treatment? Yes No If yes, date of next appointment, Comments 17. SIGNATURE OF PHYSICIAN; including degrees or credentials: (I CERTIFY that the statements apply to the medical services provided and are made a part thereof). 18. PHYSICIAN S FULL ADDRESS & PHONE: SIGNED DATE Tax I.D. #

6 MEDICAL RECORDS RELEASE AUTHORIZATION Form 6-11/2009 Fax to Texas Healthcare Foundation (972) By my signature, I do hereby authorize and give permission to all healthcare providers who have provided medical care or related services to me, to give my Employer and/or Texas Healthcare Foundation with this written authorization, complete access to all medical records pertaining to diagnosis or treatment of my Occupational Injury, disease or medical condition with respect to any physical, mental condition and/or emotional condition and/or relating to treatment for drug and/or alcohol abuse, including but not limited to records that may be protected by 42 U.S.C. 290dd-2. My permission is also given to all healthcare providers to fully discuss my diagnosis, treatment, condition, prognosis and any previous conditions that predisposed me to this Occupational Injury with my Employer and/or Texas Healthcare Foundation. I further authorize a designated representative of my Employer and/or Texas Healthcare Foundation to accompany me to any healthcare provider when receiving medical treatment or services for the Occupational Injury which occurred during my employment with my Employer. I acknowledge I may be required to submit to a drug/alcohol screening for the Occupational Injury, which requires medical treatment. I consent to the disclosure of the results of the drug/alcohol screen to my Employer and/or Texas Healthcare Foundation and hereby release my Employer, Texas Healthcare Foundation and/or testing company from any and all liability resulting from the testing procedure or the transfer of test information. I understand the information obtained by use of this Authorization will be used by Texas Healthcare Foundation to evaluate and authorize treatment for my alleged Occupational Injury while working for my Employer, to make determinations regarding eligibility for any benefits or services, and to assess the potential of my return to full or modified job duties. Any information obtained by use of this Authorization will not be released by Texas Healthcare Foundation to any person or organization EXCEPT to the insurer of any applicable policy of insurance, the reinsuring companies of such policies of insurance, employer, group policyholder, contract holder, or other persons or organizations performing business or legal services in connection with my Occupational Injury, or as may be otherwise lawfully required or as I may further authorize. This Authorization shall be valid for five years from the date shown below. Further, by my signature and full acknowledgment of medical records release, I hereby release all parties from all liabilities for any damages which may result from the furnishing of said information. Employee Printed Social Security Number X Employee Signature