Faculty: Ed Zuroweste, MD and Brent Probinsky, JD Disclosure
|
|
|
- Maximilian Hodges
- 5 years ago
- Views:
Transcription
1 Caring for the Injured Worker: Effective Partnerships between Clinicians, Health Centers and Lawyers Brent Probinsky, JD Ed Zuroweste, MD June 26, 2013 Disclosure Statement Faculty: Ed Zuroweste, MD and Brent Probinsky, JD Disclosure: We have no real or perceived vested interests that relate to this presentation nor do I have any relationships with pharmaceutical companies, biomedical device manufacturers, and/or other corporations whose products or services are related to pertinent therapeutic areas 1
2 Despite the sealing of the plant, fork lifts remained in use. 2
3 Take Away Points 1. Linkages between individual cases and mass events 2. Objective clinical tests are important. 3. Under certain conditions it is possible to go back and extrapolate to determine exposure levels. 3
4 Obstacles for Primary Care Providers/ Staff BUSY Unfamiliar terminology/ practice Public Health Paradigm Workers Compensation/ Legal system/ Reporting Office Based Elimination Substitution Engineering Controls Administrative Controls Personal Protective Equipment Injury/Exposure Management 4
5 EOH Screening Questions for the Primary Care Setting What Does a Clinician Face? A farmworker complains of nausea, headache, weakness: got sick this morning while at work 5
6 Differential Diagnosis Viral illness Food poisoning Hangover Heat exhaustion Medication reaction Malaria Pesticide poisoning Green tobacco illness Pregnancy (if female) Limited Diagnostic Tools for Clinicians 6
7 Diagnosis: The Weak Link Case Study Clinician advocate for an injured worker photo earldotter.com 7
8 Goals of Workers Compensation Medical treatment for injured patient Immediate Long term Access to Specialty Care Wages Return to Work Prevention Hazard Control Public Health Surveillance Photo earldotter.com Are undocumented workers eligible for workers compensation in your state? 8
9 What can clinicians do? Think like a lawyer! Similar to Criminal v Civil Law Criminal Beyond a Reasonable Doubt Civil More likely than not Medical Diagnosis v Occupational Exposure/Injury A Good Analogy Acquitted in the criminal case Found culpable in the civil case 9
10 What Can the Clinician Do? Document/Chart Work Related Exposure Illness Injury Consult EOH Specialist earldotter.com 1,300 employees at Quality Pork Processors 14 developed new neurological disease Was it work related? All worked near blowing brains area Only 3 plants use technique Several workers consulted company nurse actions? Interpreter reported to physician that she heard the same story from three patients 10
11 Progressive Inflammatory Neuropathy (PIN) Could have been a lot more imaginative and called it Progressive Inflammatory Globalneuropathy Syndrome PIGS What is the purpose of the Workers Compensation System? photo Scott Robertson 11
12 For the worker Injured worker entitled to immediate medical care and a percentage of lost wages. Injured worker is entitled to receive all necessary medical care for life. photo Scott Robertson For the employer Immunity from suit by employee due to any negligence by employer. No immunity for intentional acts such as battery or sexual assault against employee. photo earldotter.com 12
13 No Fault System photo earldotter.com Agriculture is classified as one of the most dangerous occupations in the US US Department of Labor photo earldotter.com 13
14 Varies from state to state. Most states allow undocumented workers to receive workers compensation benefits. Employers who hire temporary workers under the H 2A visa program are required to provide workers compensation benefits. What is Covered? Pays the injured worker a percentage of lost wages while disabled, ranging from 66% to 75% of average weekly wage. Pays the cost of all necessary medical care, diagnosis and treatment. Will include emergency care, surgery, hospitalization, physical and occupational therapy, counseling. Will cover pre existing illness or injury if new work injury was the major contributing cause of the illness or injury. New injury must cause more than 50% of injury. Will cover injuries while being transported at work from field to field, work related training and errands for employer. Death benefits for survivors of workers who die from injuries and illnesses on the job. 14
15 Other Issues Notice of claim to employer must be made as soon as possible after injury. Insurance carrier will select medical providers unless emergency treatment. Injured worker may request a onetime change of medical providers if unsatisfied. Insurance carrier must provide an interpreter, transportation or mileage reimbursement for medical visits. The insurance carrier pays for attorney s time for securing unpaid benefits. photo Scott Robertson Lump sum? The injured worker may enter a final settlement with the insurance carrier and be paid a lump sum amount in lieu of any future medical care or wage payment. Any settlement sum must be enough to compensate worker for rest of life. Be sure all surgeries and major medical treatment is completed before settling claim for lump sum photo Scott Robertson 15
16 Spotlight on Chemical Hazards Clinician must be aware of symptoms caused by exposure to toxic chemicals 1. Skin lesions and swelling 2. Nausea, vomiting, disorientation, confusion 3. Dizziness 4. Vertigo 5. Fatigue 6. Depression 7. Blurred vision 16
17 Other Follow up Notify state and local agencies of suspected chemical exposures so that formal investigations can take place Notify employer of chemical exposure by worker with date and location of exposure. Continue assistance to injured farm worker by clinician and social worker to be sure farm worker follows up with needed diagnosis and medical care. photo Scott Robertson 17
18 Claims Outside of Workers Compensation photo Scott Robertson Claims against employer for intentional acts, such as battery and sexual assault. Accidents that are caused by third parties, such as vehicles operated by persons who do not work for same employer. Defective products such as tractors, mowers, hand tools, automated packing tables that cause injury. Birth defects to child born to farm worker s chemical exposure. 18
19 Claims outside of workers compensation will allow compensation for injuries and damages that workers compensation does not allow photo Scott Robertson Questions? photo Scott Robertson 19
PATIENT REGISTARTION
PATIENT REGISTARTION Patient Name: Last First MI Address: City: State: Zip Code: Tel # (h): Tel # (w): Cell #: S.S. #: DOB: Age: Email address: Male: Female: Marital Status Spouse or Parent Name Race Preferred
Disability Coverage. Disability benefits help protect your income if you have an illness or injury that keeps you from working.
Disability Coverage Disability benefits help protect your income if you have an illness or injury that keeps you from working. Plan Highlights If you enroll in the voluntary STD benefit, you will be eligible
I further acknowledge that I have read and understand the NCAA Concussion Fact Sheet and am aware of the following information:
I, (or hereinafter on behalf of my minor child) ( Participant ), hereby acknowledge that Participant has voluntarily elected to enroll in the Lebanon Valley College Swimming Lesson / Competitive Clinic
TABLE OF CONTENTS. Eligibility for Insurance 1 Effective Date of Insurance 1. Schedule of Benefits 2 Definitions 2 Insuring Provisions 6
TABLE OF CONTENTS ELIGIBILITY FOR INSURANCE PAGE Eligibility for Insurance 1 Effective Date of Insurance 1 LONG TERM DISABILITY INSURANCE Schedule of Benefits 2 Definitions 2 Insuring Provisions 6 PREMIUMS
MCHO Informational Series
MCHO Informational Series Glossary of Health Insurance & Medical Terminology How to use this glossary This glossary has many commonly used terms, but isn t a full list. These glossary terms and definitions
Bowdoin College. Salary Continuation Plan for Faculty. Revised 10/24/13
Bowdoin College Salary Continuation Plan for Faculty Revised 10/24/13 Benefits under the Short Term Disability Salary Continuation Plan described in the following pages are provided and funded by the Employer.
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
YOUR GROUP MONTHLY DISABILITY INCOME INSURANCE PLAN
YOUR GROUP MONTHLY DISABILITY INCOME INSURANCE PLAN For Employees of Chaffey Community College District Class 2: Classified Employees 6CC000 B-12507 6-10 Elec CONTENTS OUTLINE OF COVERAGE...........................................
ALBION COLLEGE RELEASE AND WAIVER: CAMP PROGRAMS
ALBION COLLEGE RELEASE AND WAIVER: CAMP PROGRAMS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I, (or hereinafter on behalf of my minor child) ( Participant ), hereby acknowledge
Workers Compensation Guidebook
Workers Compensation Guidebook Western New York Council on Occupational Safety and Health This Guidebook is for informational purposes only, and does not constitute legal advice (or create an attorney-client
Rights to Workers Compensation Benefits and How to Obtain Them. What Are The Benefits? Workers compensation benefits can include:
THE INJURED WORKER Rights to Benefits and How to Obtain Them What Is? If you get an injury or illness on the job, your employer is required by law to provide workers compensation benefits. You could get
YOUR GUIDE TO PENNSYLVANIA WORKERS COMPENSATION. We re YOUR Workers Compensation Lawyers
YOUR GUIDE TO PENNSYLVANIA WORKERS COMPENSATION We re YOUR Workers Compensation Lawyers Table of Contents A Message From Attorney Edgar Snyder 1 Eligibility for Workers Compensation 3 Types of Workers
SALARIED DISABILITY PLAN QUICK FACTS AND QUICK LINKS
SALARIED DISABILITY PLAN QUICK FACTS AND QUICK LINKS Your Salaried Disability Coverage 1 Short-term Disability 2 Long-term Disability A Quick Look at the Disability Plans Salaried associates automatically
GROUP DISABILITY INCOME POLICY
GROUP DISABILITY INCOME POLICY Sponsor: Policy Number: Colliers International USA, LLC. GD/GF3-860-066650-01 Effective Date: January 1, 2015 Governing Jurisdiction is Washington and subject to the laws
Summary of Benefits and Coverage Distribution Instructions
Summary of Benefits and Coverage Distribution Instructions Federal law requires you, as an employer, to provide your employees with a Summary of Benefits and Coverage (SBC) at certain times. You can read
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS
Green Hills Plastic Surgery Stephen M. Davis, MD, FACS General Information Date: Patient Name: Date of Birth: Age: M.I. How would you like to be addressed by our office staff? Sex: Marital Status: Spouse
Municipal Employees Retirement System of Michigan Disability Claim Packet Instructions
Disability Claim Packet Instructions PLEASE READ CAREFULLY Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay in processing your application.
CERTIFICATE AND SUMMARY PLAN DESCRIPTION SHORT TERM MEDICAL LEAVE PLAN
Lee's Summit R-7 School District CERTIFICATE AND SUMMARY PLAN DESCRIPTION SHORT TERM MEDICAL LEAVE PLAN Plan Sponsor has established a short term medical leave plan and agreed to provide Short Term Medical
Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): Circle: MALE or FEMALE Married Status: Social Security: - -
New Patient Forms Today s Date: Name (Last, First, MI): Date of Birth: Today s Date: Street Address: City: State: Zip: Mailing Address (only if different): _ Home Phone: _ ( ) Cell Phone: _ ( ) Work Phone:
Critical Illness insurance 1
Critical Illness insurance 1 Benefit Highlights For all eligible employees of Empire Southwest, LLC, Policy #913755 If you are diagnosed with a covered condition like a heart attack or stroke critical
STATE ZIP SPOUSE OR GUARDIAN INFORMATION
REFERRED BY FAMILY DOCTOR DARRELL C. BRETT, M.D., P.C. BRET GENE BALL, LLC 10,000 SE MAIN, SUITE 360 PORTLAND, OREGON 97216 NEUROLOGICAL SURGERY PATIENT INFORMATION (PLEASE PRINT) DATE PATIENT S LAST NAME
LTD EMPLOYER'S STATEMENT
LTD EMPLOYER'S STATEMENT INSTRUCTIONS TO EMPLOYER: Complete the Employer's Statement & attach job description. Instruct employee to complete Employee's Statement and have Physician's Statement completed.
SHORT TERM DISABILITY - APPLICATION
SHORT TERM DISABILITY - APPLICATION Labourers Union Local 506 (Industrial Division) Employee Benefit Trust Fund Policy No.: 164022 Short Term Disability Application Important Information If you become
Advocate Health Care Network Disability Income Protection Summary of Benefits
Advocate Health Care Network Disability Income Protection Summary of Benefits (Amended and Restated as of July 1, 2017) What s Inside Introduction...3 Disability Case Management...4 Disability Council...4
Short-Term Disability Benefit for Non-Represented Staff. Summer 2018
Short-Term Disability Benefit for Non-Represented Staff Summer 2018 NEW BENEFIT! You asked, we delivered! To be administered through The Standard insurance company (already administers our Life Insurance
Short Term Disability
Short Term Disability General Information If you become ill or injured and are unable to work, the Hitachi Data Systems US Benefits Program can help protect you financially. The following plan has been
PATIENT INFORMATION. Last Name: First Name: Middle Initial: Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: Weight: Mailing Address:
PERSONAL INFORMATION PATIENT INFORMATION Last Name: _ First Name: _ Middle : Sex: M F Preferred Name: Date of Birth (MM/DD/YYYY): Height: _ Weight: Mailing Address: City: State: Zip: Social Security #:
Glossary of Health Coverage and Medical Terms x
Glossary of Health Coverage and Medical Terms x x x This glossary defines many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be
Disability Claim Form Instructions
Documentation required upon submitting a Disability Claim: Disability Claim Form Instructions To substantiate a claim for disability benefits covered by the Policy terms, the following documents must be
Who Administers the Workers Compensation Program and Related Responsibilities?
What is Workers Compensation? Who Administers the Workers Compensation Program and Related Responsibilities? Who is Eligible for Workers Compensation? What Coverage is Provided? What is a Compensable Injury?
ADMINISTRATIVE EMPLOYEE BENEFITS SUMMARY. For all current administrative staff (Classified and Educational Administrators):
ADMINISTRATIVE EMPLOYEE BENEFITS SUMMARY For all current administrative staff (Classified and Educational Administrators): I. Work Year: Administrators are hired to work a specific number of days per year
Definitions for Key Terms can be found on page 4
THIS IS A STATEMENT OF COVERAGE FOR THE LA SIERRA UNIVERSITY CALIFORNIA VOLUNTARY PLAN. THE PROVISIONS OF THIS STATEMENT APPLY TO DISABILITY AND PAID FAMILY LEAVE BENEFIT PERIODS BEGINNING ON OR AFTER
SHORT TERM DISABILITY CLAIM
Packet Instructions AIG Life Insurance Company* Wilmington, Delaware Delaware American Life Insurance Company* Wilmington, Delaware Member companies of American International Group, Inc. Administrative
In addition there are several aspects of your disability claim that you should be aware of:
Dear Colleague: American Airlines has partnered with Harvey Watt and Company as the Claim Administrator for the Pilot Long Term Disability Plan (the Plan). We have enclosed the Claim Application along
Optimum Health Designs
Designed for Individuals, Families & Employers (PCP or Specialist) Preventive Care Tests Diagnostic, Xray & Laboratory Emergency Room Surgery (Inpatient & Outpatient) Anesthesia Supplemental Accident for
Instructions for Enrollment forms
Instructions for Enrollment forms If you would like to elect Critical Illness coverage, please complete the form labeled Critical Illness Enrollment Form. Please complete the follow with your information:
This is only a summary. Important Questions $500 $1,000 $500 $1,000. Why this Matters: $50 $4,850 $9,700 $2,000 $4, of 10
This is only a summary. Important Questions Answers $500 $1,000 $500 $1,000 Why this Matters: $50 $4,850 $9,700 $2,000 $4,000 1 of 10 Common Medical Event Services You May Need In-network Out-of-network
Patients who are running 20 minutes late for his/her scheduled appointment will be rescheduled to the next available appointment/ day.
Orthotics/ Durable Medical Equipment Policy H2T is NEVER able to guarantee payment by medical insurance carriers for Orthotics and/or Durable Medical Equipment. H2T will bill your medical insurance as
GLOBE GADGET CARE CLAIM FORM
GLOBE GADGET CARE CLAIM FORM Important Information 1. In order to submit your claim, please complete the relevant sections. This first page must be completed for all claims. The privacy consent must be
Other Scan(s): List All Your Medical Diagnosis: Chemotherapy? YES NO If yes, please list treatment regimen:
Patient Name: Today s Date: Preferred Language: Date of Birth: Age: SSN: Race: Ethnicity: Home Phone: Cell Phone: Work Phone: Best contact phone number should we need to reach you about your treatment:
Accident and Sickness
Accident and Sickness Proof of Loss Form Important Information Notice to Insured/Claimant: Please answer all the questions completely and accurately. Indicate N.A. where question is not applicable. To
Workers' Compensation Program
Pinellas County Schools Workers' Compensation Program Manager Information Guide Risk Management & Insurance Administration Building (727)588-6196 Fax (727)588-6541 Fax (727)588-6182 (alternative) Updated:
***PLEASE PRINT USING BLACK INK ONLY***
***PLEASE PRINT USING BLACK INK ONLY*** 100 Hospital Lane, Suite 220 Danville, IN 46122 HOME PHONE WORK PHONE CELL PHONE PHARMACY LOCATION PHONE # NAME SS# ADDRESS CITY STATE ZIP BIRTHDATE AGE HEIGHT WEIGHT
THE GEORGE WASHINGTON UNIVERSITY CERTIFICATE SHORT TERM DISABILITY INCOME BENEFIT PROGRAM
THE GEORGE WASHINGTON UNIVERSITY CERTIFICATE SHORT TERM DISABILITY INCOME BENEFIT PROGRAM The George Washington University has established a short term disability (STD) income benefit Program and agreed
LVC SPORTS CENTER ACTIVITIES CAMP JUNE 11 14, 2018
LVC SPORTS CENTER ACTIVITIES CAMP JUNE 11 14, 2018 All campers will receive a 2018 camp T-shirt Lunch is served each day All campers must be dropped off and picked up at the LVC Sports Center each day
W E L C O M E. Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By
W E L C O M E PATIENT INFORMATION Name Date Address Apt # City State Zip Code Phone #: Home Cell Work Referred By Date of Birth Social Security # - - Gender: Male Female Marital Status (please circle):
CONTENTS OUTLINE OF COVERAGE... 1 CERTIFICATION PAGE... 2 SCHEDULE OF BENEFITS... 3 EMPLOYEE'S INSURANCE... 5 DISABILITY INCOME INSURANCE...
CONTENTS OUTLINE OF COVERAGE........................ 1 CERTIFICATION PAGE.......................... 2 SCHEDULE OF BENEFITS........................ 3 EMPLOYEE'S INSURANCE....................... 5 DISABILITY
Marital Status Patient s Last Name First Initial Date of Birth S M D W. Home Phone Work Phone Mobile Phone . Address City State Zip
PATIENT INFORMATION Marital Status Patient s Last Name First Initial Date of Birth S M D W Home Phone Work Phone Mobile Phone E-Mail Address City State Zip Occupation Employer Employer Phone Employer Address
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA Mills Meyers Swartling GROUP POLICY NUMBER - 222551-001 BOOKLET EFFECTIVE DATE - April 1, 2012 BOOKLET AMENDMENT DATE - 93C-LH
Summary of Benefits and Coverage (SBC) & Uniform Glossary A Supplement to the Insurance & Benefits Information Guide
2017-2018 Summary of Benefits and Coverage (SBC) & Uniform Glossary A Supplement to the 2017-2018 Insurance & Benefits Information Guide Nassau County School Board 1201 Atlantic Avenue Fernandina Beach,
THE CLAIMS PROCESS. Your guide to the claims experience
THE CLAIMS PROCESS Your guide to the claims experience I was injured at work, what do I do now? A quick overview of what will happen next... 1. 2. 3. 4. Report your injury The claim process starts when
WHAT YOU SHOULD KNOW WHEN YOU HAVE BEEN INJURED IN A MOTOR VEHICLE ACCIDENT
WHAT YOU SHOULD KNOW WHEN YOU HAVE BEEN INJURED IN A MOTOR VEHICLE ACCIDENT This document provides current information about obtaining assistance to meet your needs through insurance benefits and other
Paid Sick Leave Laws: State Comparison Chart
District of Columbia D.C. Code 32-131.01 -.17 11/13/2008 (amendments eff. 2/22/2014) All employers (subject to differing accrual requirements based on size). Employees immediately accrue leave but can
Topic: ON-THE-JOB INJURY AND ILLNESS POLICY. Policy #: Version: 1.2 Revision Date: 8/1/12
HUMAN RESOURCES POLICY MANUAL Topic: ON-THE-JOB INJURY AND ILLNESS POLICY Policy #: 704.00 Version: 1.2 Revision Date: 8/1/12 A. GENERAL POLICY 1. The Workers' Compensation Act of the State of Alabama
The Long Term Disability Benefits application includes claim forms and an Authorization.
Long Term Disability Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for Long Term Disability benefits. Every space on these forms should
Registration Form. Gender: Male Last Name First Name Middle Initial Female. - - / / Social Security Number Date of Birth Age Occupation / Employer
Registration Form General Information Have you been treated by us before? Yes No Gender: Male Last Name First Name Middle Initial Female Social Security Number of Birth Age Occupation / Employer Street
Prepared for: Socorro Independent School District
Offered by Life Insurance Company of North America (a Cigna company) Employee-Paid LONG-TERM DISABILITY INSURANCE POLICY Prepared for: Socorro Independent School District SUMMARY OF BENEFITS If you had
appointment checklist
appointment checklist Dear parents: The staff of Cook Children s Pediatric Gastroenterology (GI) and Nutrition Clinic appreciates your selection of our physicians to serve you and your child s needs. Our
University Policy WORKERS COMPENSATION
University Policy 200.23 WORKERS COMPENSATION Responsible Administrator: Executive Vice President Responsible Office: Office of Human Resources Originally Issued: March 2009 Revision Date: Authority: Office
Office Overhead Expense
Office Overhead Expense COVERING OFFICE EXPENSES IF ILLNESS OR INJURY KEEPS YOU FROM WORKING If you suffer a disabling injury or illness, Long Term Disability Insurance will help protect your income. But
Veritas Management Group EMPLOYEE BENEFITS
Veritas Management Group EMPLOYEE BENEFITS Benefit plans effective February 1, 2017 January 31, 2018 Table of Contents How Benefits Work Benefits Eligibility... 3 Enrollment... 3 Changing Your Benefits
Sun Life Assurance Company of Canada
Short Term Disability Claim Packet Instructions for the Plan Administrator An initial claim for Short Term Disability benefits should be submitted when a disability absence has actually begun, and it first
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: PATIENT INFORMATION
CENTRAL FLORIDA ORAL & MAXILLOFACIAL SURGERY, PA PATIENT REGISTRATION Date: Pre-fix: Patient s Legal First Name: PATIENT INFORMATION Legal Last Name: Nickname: Mr Mrs Ms Dr Street Address: Home Phone #:
YOUR RIGHTS UNDER THE MISSOURI WORKERS COMPENSATION LAW
YOUR RIGHTS UNDER THE MISSOURI WORKERS COMPENSATION LAW What is the Workers Compensation Law? The workers compensation law, found in Chapter 287 of the Revised Statutes of Missouri, controls the rights
Volusia County School District
Educator Salary Protection Insurance Plan Volusia County School District Disability Insurance Plans are offered and underwritten by Unum Life Insurance Company WHAT IF YOU WEREN'T GETTING A PAYCHECK? Chances
Glossary of Health Coverage and Medical Terms
Glossary of Health Coverage and Medical Terms This glossary defines many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different
SURA/JEFFERSON SCIENCE ASSOCIATES, LLC
SURA/JEFFERSON SCIENCE ASSOCIATES, LLC COMPREHENSIVE HEALTH AND WELFARE BENEFIT PLAN Summary Plan Description Amended and Restated Effective April 1, 2011 YOUR SUMMARY PLAN DESCRIPTION This document is
CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS
DETACH THIS PAGE AND KEEP FOR YOUR RECORDS CLAIMANT RIGHTS AND RESPONSIBILITIES RULES FOR FILING A CLAIM AND APPEAL RIGHTS 1. It is your responsibility to file this claim form promptly after you stop working
Allowable Expenses. Assigned Claims Facility. Attendant Care. Adjuster. Case Manager. Catastrophic Injury. Causation.
The following list defines various words/lingo used throughout this website, by No-Fault adjusters and insurance company, and by attorneys specializing in the No-Fault law. Allowable Expenses Assigned
Cancer Supplemental Insurance Policy with Transplant & Chronic Illness
Marketed by Cancer Supplemental Insurance Policy with Transplant & Chronic Illness SUPPLEMENTAL INSURANCE POLICY Insurance Coverage underwritten by R. 9-2-15 Cancer Lump Sum Benefit 1 50,000 * CANCER LUMP
MoDOT & Patrol Employees Retirement System MPERS Disability Benefits Claim Packet Instructions
Claim Packet Instructions PLEASE READ CAREFULLY Your application for benefits consists of four forms. Every space on these forms should be filled in to avoid delay in processing your application. If a
PLACENTIA-YORBA LINDA UNIFIED SCHOOL DISTRICT
PLACENTIA-YORBA LINDA UNIFIED SCHOOL DISTRICT CLASSIFIED LEAVE HANDBOOK Revised 01/15/15 PLACENTIA-YORBA LINDA UNIFIED SCHOOL DISTRICT Summary of Classified Employee Leaves of Absence Employee needs to
true group and voluntary products
true group and voluntary products EMPLOYER CONTRIBUTION AND PARTICIPATION REQUIREMENTS Employer paid When the employer contributes 100 percent of the cost, 100 percent employee participation is required.
FLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT
FLORIDA TECH EMPLOYEE ACCIDENT/ INJURY REPORT Contact Financial Affairs @ 674-7297 OR 8885 IMMEDIATELY regarding an Employee's Injury. Employee AND Supervisor must complete this report. EMPLOYEE INFORMATION
Patient Registration Form
PATIENT INFORMATION Patient Name: of Birth: Age: Marital Status: Married Single Home Phone: Email: Address: Cell: SS#: Divorced Patient Registration Form Account Number: Gender: Widowed Separated Unknown
INJURY EVALUATION & INSURANCE PROCEDURE
INJURY EVALUATION & INSURANCE PROCEDURE A. Evaluations Injury evaluations are an important part of athletics and one of the functions of an athletic trainer. An injury/illness evaluation helps to determine
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you!
New Patient Packet Please print and complete the following 6 pages. Bring the completed forms to your scheduled appointment. Thank you! Washington Ear, Nose and Throat 80 Landings Drive, Suite 207 Washington,
Guide. to Recovery Under The Illinois Workers Compensation Act. The Injured Employee s
The Injured Employee s Guide to Recovery Under The Illinois Workers Compensation Act Prepared By: Romanucci & Blandin, LLC 33 North LaSalle Street, 20th Floor Chicago, Illinois 60602 Toll Free: 888.458.1145
Unified Health. For Individuals and Families in. California, Iowa, Tennessee, and Indiana
Unified Health Limited Health Insurance For Individuals and Families in California, Iowa, Tennessee, and Indiana 00% Guaranteed Coverage for Individuals and Families Who Cannot Afford or Qualify for Full
Group Disability Claim Filing Instructions
Claims Department P. O. Box 925 Group Disability Claim Filing Instructions IMPORTANT: All portions of this claim form must be completed after disability begins to avoid undue delay in processing claimant
BENEFIT PLAN. What Your Plan Covers and How Benefits are Paid. Prepared Exclusively for California Institute Of Technology
BENEFIT PLAN Prepared Exclusively for California Institute Of Technology What Your Plan Covers and How Benefits are Paid Life Insurance, Dependent Life Insurance and Accidental Death and Personal Loss
2. Pregnancy, childbirth, and recovery (Education Code 45193)
AR 4261.1(a) Classified employees employed five days a week are entitled to 12 days' leave of absence with full pay for personal illness or injury (sick leave) per fiscal year. Employees who work less
Penske Long-Term Disability Summary Plan Description
Penske Long-Term Disability Summary Plan Description Contents Program Highlights... 1 Coverage Available to You...1 Eligibility and Enrollment... 2 Eligibility... If You Are a New Hire... If You Transfer
Veritas Management Group EMPLOYEE BENEFITS
Veritas Management Group EMPLOYEE BENEFITS Benefit plans effective February 1, 2016 January 31, 2017 Table of Contents How Benefits Work Benefits Eligibility... 3 Enrollment... 3 Changing Your Benefits
YOUR GROUP DISABILITY INSURANCE PLAN
YOUR GROUP DISABILITY INSURANCE PLAN For Employees of CITY OF MERCED 6CC000 B-12958 4-11 (700) CONTENTS OUTLINE OF COVERAGE........................................... 1 CERTIFICATION PAGE.............................................
My employees need a health plan they can trust. I need a plan that lets them control their costs.
My employees need a health plan they can trust. I need a plan that lets them control their costs. BUSINESS BLUE HDHRA This is our plan. Business Blue SM High Deductible for Health Reimbursement Accounts
Please send your completed form to: Claims Department P.O. Box Atlanta, Georgia 30342
** THE ATTACHED FORM IS TO BE USED IN FILING FOR DISABILITY BENEFITS ** PLEASE FOLLOW THESE INSTRUCTIONS CAREFULLY 1) The Loan Information Statement at the top of the claim form should be completed by
Workers Compensation: Please be advised that in the event your claim is denied, you are financially responsible for all charges.
Welcome to Lake Burien Physical Therapy, Inc (LBPT). We bill your insurance company as a courtesy to you. We verify your insurance coverage; however, this is not a guarantee of payment. Please keep in
Workers Compensation Basics
Workers Compensation Basics What is work comp and what does it cover? Workers compensation coverage is an employee benefit that is mandated by law, which differs by each state, and covers employees for
Section 4: Authorization for Use and Disclosure of Protected Health Information Between WEA Trust Plans
Instructions This form or other similar written notice of claim must be submitted within 90 days of the onset of your alleged disability. If you have any questions, call WEA Trust at 608.276.4000 or 800.279.4000.
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty
FLORIDA MEDICAL CLINIC, P.A. Your Life, Our Specialty Consent for Purposes of Treatment, Payment and Health Care Operations I consent to the use or disclosure of my protected health information by Florida
For: Choice POS II High Deductible Health Plan - Faculty, Managerial & Professional Employees
Schedule of Benefits Employer: Yale University ASA: 877076 Issue Date: July 28, 2017 Effective Date: January 1, 2017 Schedule: 6A Booklet Base: 6 For: Choice POS II High Deductible Health Plan - Faculty,
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA. City of South Lake Tahoe
Employee Group Benefits UNDERWRITTEN BY SUN LIFE ASSURANCE COMPANY OF CANADA City of South Lake Tahoe Short Term Disability and Long Term Disability Insurance GROUP POLICY NUMBER - 85331 POLICY EFFECTIVE
I. Disability Income and Related Insurance 12 items
Table of Contents I. Disability Income and Related Insurance... 1 A. Benefit Limits and the purpose of disability income... 1 1) Pure Loss of Income/ Indemnity... 1 2) Insuring Agreement... 1 B. Qualifications
Standard Bank Unity Hospital Cash Plan
Standard Bank Unity Hospital Cash Plan Standard Insurance Limited Registration number: 1993/007593/06 Between Standard Insurance Limited (Us) and the Policyholder (You) 1 Important information about the
LOYAL AMERICAN LIFE INSURANCE COMPANY PO BOX 1604, DUNCAN, OKLAHOMA, Phone (800)
INSTRUCTIONS FOR FILING A MEDICAL CLAIM CANCER TREATMENT The forms must be completed by the claimant. All questions on the forms must be answered in full. Incomplete or illegible answers may result in
What to Know About Your Health Plan
What to Know About Your Health Plan 1 Given the ever changing nature of health care, it s no surprise many people have a diffcult time understanding their health benefts. However, learning the basics of
Halfway House General Liability Application
P.O. Box 14770, Scottsdale, AZ 85267-4770 8475 E. Hartford Dr., Scottsdale, AZ 85255 (480) 991-7889 WATS (800) 848-8860 Fax (480) 948-1394 Toll Free (866) 240-8807 P.O. Box 571770, Murray, UT 84157-1770
Financial protection for what matters most
CROSS RIVER BANK 885 TEANECK RD TEANECK, NJ 07666 Don t miss your chance to sign up for this valuable coverage. Enroll by July 14, 2016. CROSS RIVER BANK Financial protection for what matters most Employee,
Standard Operating Procedures
Standard Operating Procedures Title: Accident/Incident Reporting Purpose: This SOP details the procedures and requirements for reporting and investigating a safety or environmental incident or loss at