GIVE TO INJURED EMPLOYEE PACKET

Transcription

1 GIVE TO INJURED EMPLOYEE PACKET 1) Authorization form Ensure they sign before getting treatment. 2) Prescription Sheet in case the doctor issues a prescription. 3) Physician s Report / Pharmacy Guide Ensure employee understand this has to be filled out by the Physician. 4) Injury/Illness Reporting Information Fill out completely! 5) On the Job Injury Reporting Policy MAKE SURE YOU Please forward a copy of the signed Authorization form & Physician s Report / Pharmacy Guide to Human Resources. Have the injured employee read the entire content of the packet. Inform injured employees that do not follow Johnston County s policy are subject to denied claims, and delays in Workers Compensation payment(s). Report injuries to Key Risk and Human Resources within 24 hours online.

2 Authorization The undersigned has filed a claim for workers compensation benefits (hereinafter referred to as the Claim ). The amount and type of information sought pursuant to this authorization will depend upon the nature of the Claim, but will be used solely to facilitate determination regarding the validity of the Claim and the payment of benefits or the administration of the insurance program under which the Claim has been made. Authorizing the disclosure of information is voluntary, and acceptance of the Claim will not be conditioned upon signing this authorization. This authorization is subject to revocation at any time, except to the extent that any party has already acted in reliance upon it. Any revocation must be submitted in writing to Key Risk, P.O. Box 49129, Greensboro, NC The undersigned authorizes the release of information and communication between his or her health care provider(s) and representatives of Key Risk Management Services, LLC or Key Risk Insurance Company ( Key Risk ). This release of information applies to all applicable medical records, medical information, and benefit payment information with respect to any illness, injury, medical history, consultation, prescription, treatment, or benefit, and copies of all applicable records thereof, which may be appropriate or necessary throughout the course of this Claim. This authorization shall specifically include, but shall not be limited to, medical records, medical information and benefit payment information pertaining or relating to the treatment of Acquired Immune Deficiency Syndrome, HIV, mental illness, and drug or alcohol related medical problems. The undersigned also authorizes the Social Security Administration and the Centers for Medicare & Medicaid Services (CMS), its agents and/or contractors, to release to Key Risk information concerning his or her workers compensation injury, entitlement dates and benefit amounts. The undersigned further authorizes Key Risk to release any such information to its reinsurers, attorneys, second injury fund consultants, or to medical peer review panels, CMS, state insurance or fraud agencies, managed care vendors, industry anti-fraud or law enforcement organizations, research and statistical reporting organizations, or the undersigned s employer and its excess insurer, to the extent that Key Risk considers doing so to be reasonably appropriate or necessary for purposes of its administration of the Claim or the insurance program under which the Claim has been made. Information disclosed to Key Risk is from records whose confidentiality is protected by various state or federal laws. Any further disclosure of this information may no longer be subject to certain protections provided under federal privacy regulations. Unless revoked earlier by the undersigned, in writing, this authorization shall be valid for three years after Key Risk has closed the Claim. A copy of this authorization is to be considered as valid as the original. Employee Signature Date Employee Name (Please Print) Employer (Please Print) A

3 Instant Access Card Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your worker. Injured Worker: 1. If you need a prescription filled for a work-related injury or illness, go to a participating pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Instant Access For Your First Prescription Fill Name: Social #: Employer: RxBIN: RxPCN: IRX Customer Service: (800) Prescription Plan ATTENTION PHARMACISTS: Please process this prescription through Catamaran: For questions regarding transmission or rejections, Please call Modern Medical at ATTENTION INJURED PARTY: Use of this prescription card is restricted to prescriptions for your allowed condition only. To receive your medication coverage, present this card to a participating pharmacy. For questions, please call Modern Medical at Pharmacist: 1. Call Modern Medical s Pharmacy Department at Provide the information listed above. 3. The Help Desk will provide an ID number and group number for adjudication. Finding a Network Pharmacy Most common chains participate in the Modern Medical Pharmacy Network. Some of these include: CVS, Rite-Aid, Wal-Mart, Giant Eagle, Kroger, Meijer, Costco, Target, etc. Contact Modern Medical and we ll help you locate the closest network pharmacy: 1. Call us at Use our Find a Pharmacy search tool at modernmedical.com

4 Physician s Report / Pharmacy Guide MAILING ADDRESS: P.O. Box 49129, Greensboro, NC EMPLOYER: Please complete the top section and give to the injured employee to take to his or her authorized treating physician. If you already have transitional duty job descriptions available, please attach a copy for the treating physician s review. Name of Employee/Patient: Last: First: Date of Injury: Name of Employer / Company: Employer Signature: Name of Doctor Chosen: EMPLOYEE: Please take this form with you to an authorized treating physician. Please have the physician complete the middle section and return this immediately to your employer. The bottom section is for you to show the pharmacist should you need to have any prescriptions filled as prescribed by your authorized treating physician for this work related injury. AUTHORIZED PHYSICIAN, PLEASE COMPLETE Diagnosis: A post accident drug test has been completed or has not been completed (check one) In accordance with this patient s physical capability, check all that apply: May resume work immediately with no restrictions May resume work immediately with the following restrictions: Sedentary work (sitting, occasional walking, standing, lifting less than 10 pounds) Light work (lifting less than 20 pounds) Medium work (lifting less than 50 pounds) Heavy work (lifting less than 100 pounds) Normal shift Limited hours per day: 2 hours; 4 hours; 6 hours Other: Repetitive Motion Restrictions (specific to hand/arm injuries): Frequency Left Right Both No Use Occasional <33% of time Frequent 34-66% of time Regular % of time Patient may return to work at full duty on (date): Patient has a return appointment on (date): Please indicate any referrals that are required: at (time) Physician s Signature Date Physician s Name (type or print) Contact Key Risk s Claim Department at for authorization for the referral. PHARMACIST: Process all prescriptions through Modern Medical for this patient. Contact the Modern Medical at (800) to establish eligibility. DO NOT CHARGE THE PATIENT FOR THE PRESCRIPTION Walgreens Leader Drug Stores King Soopers Food Lion Pamida Pharmacy Medicine Chest Pharmacies CVS K-Mart Medicap Pharmacies Dillon Pharmacies Wegmans Ross Park Pharmacy Rite Aid Ahold Fred s Pharmacy Life Check Kinney Drugs Northeast Pharmacy Services Wal-Mart The Medicine Shoppe Brookshire s United Supermarkets Bioscrip Brookshire Brothers Food & Pharmacy Giant Eagle Pharmacies Family Care Albertsons/Sav-On Smith s Pharmacy Spartan Stores Kroger Long s Drug Stores Raley s The Vons Companies U Save Pharmacy Meijer Bashas Hannaford Brothers Sav-Mor Drug Stores Randall s Food & Drug Costco Harris Teeter Hy-Vee Pavilion Plaza Pharmacy Foodarama Supermarkets Publix Super Markets Kerr Drug Ingles Markets Kash N Karry Unity Pharmacies Please call for additional participating Albertsons Winn-Dixie Stores Aurora Pharmacy Supervalu City Market pharmacies. Farm Fresh Major Value True Care Perlmart Thrifty White Access Health RxPride Save Mart Supermarkets JH Harvey Super D Drugs Tom Thumb Randall s Food & Drug Target Safeway Pharmacies Shopko Stores Bi-Lo Pharmacy K-VAT-T Food Stores Pharmacy Express RMS B Working Together. Delivering Better Outcomes.

5 REPORT OF INJURY ON-THE-JOB JOHNSTON COUNTY This report is to be filled out by the employee for each accident/injury and returned to the Supervisor to be forwarded to the Risk Management Coordinator within 24 hours. I am reporting a work related: Injury Illness Near Miss Name: Dept./Div.: Social Security Number: Home Phone: Address: Work Phone: Date of Birth: Job Title: Hire Date: Time Employee s Shift Began: a.m. p.m. INJURY / ILLNESS / NEAR MISS Date of Injury/Near Miss: Time: a.m. p.m. Physical Work Location Where Injury/Near Miss Occurred: Date First Reported to Supervisor: Name of Supervisor To Whom Injury/Near Miss Reported: Description of Injury (i.e., cuts, bruises, fractures, right arm, left leg, etc.) Description of how injury/near miss occurred: List any unsafe act(s) or condition(s) that, in your opinion, helped cause the injury/near miss: PREVENTION: How could this Injury/Near Miss have been prevented? Was injury/near miss directly related to employee s job? Was injury/near miss the result of carelessness? Name and Address of Witnesses: Name: Address: Name: Address: (Continue on back) Rev 01/15/15

6 MEDICAL CARE: Was a physician, hospital or Urgent Care center contacted? Date: Time: AM / PM Name & Address of Physician or Urgent Care Center: Phone Number: Name & Address of Hospital: Phone Number: EMPLOYEE: I certify that the above information is an accurate account of my injury/near miss. I further understand that I may be prosecuted under applicable state laws for making false claims or statements in order to receive workers compensation. Employee's Signature Date SUPERVISOR: This is to certify the above information to be correct to the best of my knowledge and belief. I further certify that the injury/near miss occurred while the employee was engaged in duties required of his/her position. Supervisor Signature Date NOTE: The Department Head or Supervisor should provide a Personnel Action Form (PAF) specifying the exact dates the employee is out of work. Employees may elect to use available vacation, sick, or compensatory leave in lieu of leave without pay during the first seven days of injury and throughout workers compensation leave. Should the injury cause the employee to be out of work for more than seven days, the employee will be paid through our Workers Compensation carrier until they return to work. Accrued leave cannot be used past the first 7 day waiting period. Failure to notify the Human Resources Office through a PAF of the employee returning to work could result in them not receiving their wages in a timely manner or them being overpaid by workers compensation. NOTE: Failure to complete and return this form promptly may result in delay and/or denial of Worker's Compensation benefits. Received in Risk Management Filed with Workers Comp Carrier Posted to OSHA Log (If appl.) For office use Rev 01/15/15

7 Johnston County Injury occurs from work related accident/illness Employee reports event to supervisor Reporting Procedures For Injury On-The-Job Supervisor completes Report of On-the-Job Injury forms Employee Returns to Work No Is medical treatment necessary? Later Employee Requires Medical Treatment Yes Is the Event an Emergency? Yes Call 911 Employee goes to closest ER No Send employee to: QuickMed / NOVA Urgent Medical Care Employee sees physician No Does Employee Return to Work? Yes No With Restrictions? Yes Supervisor monitors employees progress, employee and supervisor obey restrictions, stay in contact with Risk Management Coordinator Notify Supervisor and Do FMLA / Personal Leave Paperwork! Does employee need additional treatment? No Employee returns to work Yes

8 JOHNSTON COUNTY ON THE JOB INJURY REPORTING Safety Manual REV SUPERSEDES EFFECTIVE DATE PAGES 07/17/02 08/14/ PURPOSE: To provide policy and procedures on the reporting of a work-related injury by County employees engaged in County business. This policy coincides with North Carolina Workers Compensation. 2.0 ORGANIZATIONS AFFECTED: Compliance with this policy is mandatory for all County departments. 3.0 DEFINITIONS 3.1 COUNTY PHYSICIAN means the physician(s) agreeing to perform workers compensation medical service for Johnston County and its employees. Initial visit is always with Urgent Care (Smithfield) the medical practice agreeing to perform this service. QUICK MED (Medical Mall) 514 N Bright Leaf Blvd., Suite 1620 Smithfield, NC Hours of Operation: Frequently change and are typically open M-F 9am 5pm. Health Zone 707 Lassiter St. Smithfield, NC Hours of Operation: Frequently change and are typically open M-F 8am 7pm. Sat. 9am-6pm Sun. 11am 6pm. Smithfield Crossing 388-I Venture Dr. Smithfield, NC Hours of Operation: Frequently change and are typically M-F 9am 8pm. Sat. 10am-6pm Sun. 10am-6pm. 3.2 COMPENSABLE INJURY means an injury by accident arising out of and in the course of employment. WORKERS COMPENSATION CARRIER means Key Risk P.O. Box Greensboro NC Johnston County Contact Hugh Bennett, Senior Claims Representative PO Box Greensboro, NC phone: x fax: hbennett@keyrisk.com

9 JOHNSTON COUNTY ON THE JOB INJURY REPORTING Safety Manual 4.0 REPORTING 4.1 Employees will report all injuries, no matter how small or insignificant to their supervisor immediately. 4.2 The supervisor shall be responsible for getting the injured employee medical attention. 4.3 The Authorization for Treatment form for authorizing medical treatment shall be signed by the employee prior to the medical treatment the supervisor will take the employee to the medical facility. 4.4 Once the employee has been seen by the physician, the Supervisor will forward the completed Physician Report / Pharmacy Guide form to the Risk Management Coordinator within 24 hours. 5.0 AFTER HOURS REPORTING 5.1 The employee shall notify his supervisor as soon as practicable that he received medical attention after work hours. 5.2 Supervisor shall have the employee sign the Authorization for Treatment form and inform Human Resources that the employee visited the hospital emergency room after hours. 5.3 Once the employee has been seen by the physician, the Supervisor will forward the completed Physician Report / Pharmacy Guide form to the Risk Management Coordinator within 24 hours. NOTE All work-related injuries that involve hospital admission and/or fatality will require immediate notification of the Human Resource Director regardless of the time of day. Additionally, the Human Resource Director ( ) will be notified if more than one employee is injured at any one incident. If the Human Resources Director cannot be contacted at their work phone, then Johnston County Communications (911) will be contacted and have both parties contacted. 6.0 FOLLOW-UP REQUIREMENTS 6.1 The County physician(s) will see all injuries that are deemed work-related and covered by the North Carolina Workers Compensation law. 6.2 Injured employees must continue to see the County physician(s) for any follow-up visits unless referred out to a specialist by the County physician(s), Human Resources, or Key Risk. 6.3 If the employee desires a second opinion, permission must be obtained by the Risk Management Coordinator and/or Key Risk before visiting another physician. 6.4 Employees are to provide copies of doctor s notes after appointments to the the Human Resources Department and are to keep the department apprised of any changes that may occur with care or the injury.

10 JOHNSTON COUNTY ON THE JOB INJURY REPORTING Safety Manual 6.5 The Human Resources Department must be notified in writing by a physician of any restrictions and/or full release before an employee can return to light or fully duty work. NOTE Failure to adhere to paragraph 6.0 may result in denial and/or discontinuance of Workers Compensation benefits and the employee having to pay all medical treatment costs out of their pocket. Payment of personal physician services for a Workers Compensation injury may be denied. It is important that department heads/supervisors maintain contact with the Risk Management Coordinator throughout the injured employee s recovery as information such as days away from work, restricted days, and/or any vacation days must be reported not only to Key Risk, but also tracked for NC OSHA requirements. 7.0 USE OF EMERGENCY ROOM JOHNSTON MEMORIAL HOSPITAL ONLY The employee may utilize the Hospital emergency room only for the following: 7.1 After work hours, and when County physician(s) (Urgent Care) is closed, or 7.2 Injuries that require hospital admittance, or 7.3 Life-threatening emergencies. 8.0 USE OF EMS/RESCUE SQUAD If the injury is a life-threatening situation, or will require hospital admittance, EMS/Rescue Squad shall be the primary carrier for the employee to the emergency room. 9.0 ACCIDENT/INJURY INVESTIGATION 9.1 The employee will complete the injury report which can be accessed online ( describing in detail how the injury happened, the extent and location of injury, what unsafe act, condition, or combination of any, caused the injury, and a list of any witnesses. 9.2 The supervisor will investigate the accident certifying that the information given is accurate. If information is not accurate the supervisor will inform the Human Resources Department and Risk Management will follow up with an accident investigation.

11 Johnston County Employee s Injury/Illness Reporting Information To Injured Employee: EMPLOYEE PAY First Seven Days Employees out of work for the first seven days due to a compensable injury/illness will be placed on leave without pay status. However, employees may elect to use available vacation, sick, or compensatory leave in lieu of leave without pay during this time. Department Heads must complete a payroll action form (PAF) and forward it to Human Resources noting your status. The first seven days include weekends and/or holidays. If you are out more than seven days, you will be paid Workers Compensation pay, which is two-thirds of your regular wages. Longer than Seven Days: If your injury causes you to be out of work longer than seven days, you will be paid through Key Risk Claims Management Services. Again, to receive full pay, you may elect to supplement the difference in pay using any available vacation, sick, or compensatory leave. After 21 Days: If your injury causes you to be out longer than 21 days, you will then be paid for the first seven days missed at the beginning of the injury period. You must be out that 22 nd day before this will happen. This pay comes from Key Risk Claims Management Services and as other workers compensation checks, does not have withholdings or taxes taken from it. If you used any comp, vacation or sick leave to supplement your first seven days, once you exceed the 22 nd day, you will be reimbursed at one-third percent, your comp, vacation or sick leave used in that period. Note: regardless of whether you elect to supplement your pay, you must contact the Human Resources Department ( ) to arrange for payment of your contributions for your benefits (i.e., health insurance, dental, life, disability), as deductions cannot be taken from your Workers Compensation paycheck. PRESCRIPTIONS When having a prescription filled, tell your pharmacy that you are under the TMESYS pharmacy program. As long as your pharmacy is a member of this network, they should fill your prescription at no charge to you and then they will file it with TMESYS. Attached is additional information about this plan. If your pharmacy is not a member of this program, attached to this packet is a Form 25P where you can be reimbursed for any out-of-pocket prescription expenses you may incur. Pharmacy Locator SUMMARY While you are out on Workers Compensation leave, it is important you continue communication with your Department Head and/or supervisor about information such as your progress, time projected away and/or return date as prescribed by your physician, etc. You are to also cooperate with our Workers Compensation carrier and keep them informed of your progress. Failure to communicate Rev. 9/30/09

12 with all parties could complicate your claim, delay your benefits, and possibly result in the discontinuance of your Workers Compensation benefits. If you have any questions or need assistance, don t hesitate to call. Johnston County Human Resources Carrier: Key Risk P.O. Box Greensboro, NC Hugh Bennett extension hbennett@keyrisk.com Fax Rev. 9/30/09

13 North Carolina Industrial Commission IC File # ITEMIZED STATEMENT OF CHARGES FOR DRUGS Emp. Code # Carrier Code # The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Employer FEIN ( ) Employee s Name Employer's Name Telephone Number Address Employer s Address City State Zip City State Zip Insurance Carrier ( ) ( ) Home Telephone Work Telephone Carrier's Address City State Zip D M D F / / ( ) ( ) Social Security Number Sex Date of Birth Carrier's Telephone Number Fax Number DATE DRUG STORE CITY NAME OF DRUG & PRESCRIPTION NO. PHYSICIAN AMOUNT TOTAL $ This is to certify that the drugs listed above were related to my workers' compensation injury. (Receipts must be furnished for carrier's file) Employee signature Carrier s approval Reimburse employee Yes D no D EMPLOYEE: Mail your bill in duplicate promptly to employer and/or insurance carrier Reimburse drug store Yes D no D EMPLOYER OR CARRIER/ADMINISTRATOR: DRUGS MAY BE REIMBURSED DIRECTLY TO THE EMPLOYEE OR DRUG STORE. IT IS NOT NECESSARY TO SUBMIT BILLS TO THE COMMISSION FOR APPROVAL. PAY AND RETAIN COPY IN CARRIER S FILE. NCIC - MEDICAL BILLING SECTION 4337 MAIL SERVICE CENTER RALEIGH, NC MAIN TELEPHONE: (919) HELPLINE: (800) WEBSITE: FORM 25P

14 North Carolina Industrial Commission IC File # ITEMIZED STATEMENT OF CHARGES FOR TRAVEL Emp. Code # Carrier Code # The Use Of This Form Is Required Under The Provisions of The Workers' Compensation Act Carrier File # Employer FEIN Employee s Name Employer's Name Telephone Number Address Employer s Address City State Zip City State Zip Insurance Carrier ( ) - ( ) - Home Telephone Work Telephone Carrier's Address City State Zip - - M F / / ( ) - ( ) - Social Security Number Sex Date of Birth Carrier's Telephone Number Fax Number Employees are entitled to reimbursement of $0.555 per mile for travel for medical treatment, provided they travel 20 miles or more roundtrip, starting July 1, (The mileage rate is $0.51 for January 1-June 30, 2011; $0.50 for 2010; $0.55 for 2009; $0.585 for July 1-December 31, 2008; $0.505 for January 1-June 30, 2008; $0.485 for 2007; $0.445 for January 18-December 31, 2006; and $0.31 for travel before that date.) Special consideration will be given to employees who are totally disabled. No reimbursement is allowed for trips to purchase medications or supplies unless medically necessary. These items must be purchased on visits to medical providers (G.S ). DATE NAME OF MEDICAL PROVIDER CITY TOTAL MILES ROUNDTRIP / / / / / / / / / / OTHER EXPENSES If overnight stay is necessary, the following items will be approved as submitted. (Receipts must be furnished for carrier s file.) Total motel expense ($45.00 per day): Total meal expense ($6.00 Breakfast, $8.00 Lunch, and $14.00 Dinner): Total parking & cab expense (actual charge): Total for other expenses: Total Miles: X [mileage rate]* Other expenses: Total all expenses: *The mileage rate is $0.555 for travel, starting July 1, 2011; $0.51 for January 1-June 30, 2011; $0.50 for 2010; $0.55 for 2009; $0.585 for July 1 to December 31, 2008; $0.505 for January 1 to June 30, 2008; $0.485 for 2007; $0.445 for January 18 to December 31, 2006; and $0.31 for travel before that date. I hereby certify that I have incurred all expenses listed above as a result of my workers' compensation injury. Employee signature Employee: Mail your bill in duplicate promptly to employer and/or insurance carrier Carrier s approval Employer or Carrier/Administrator: Travel may be reimbursed directly to the employee. It is not necessary to submit bills to the Commission for approval. Pay and retain copy in carrier's file. FORM 25T

15 For Assistance, Call: N.C Industrial Commission Main Telephone: (919) Workers Compensation Information Specialists: (800)