Office of Risk Management 4850 South Yosemite Street Greenwood Village, Colorado 80111 720-554-4643 FAX: 720-554-4641 TO: FROM: Cherry Creek School District Employees Karyn Fast, Risk Manager Sherry Williams, Risk Management Specialist Christine Baxter, Risk and Opportunity Specialist Jody Prentice, Risk Management Specialist DATE: January 1, 2019 SUBJECT: Workers Compensation (1) Administration (2) Procedures Workers Compensation claims are administered by the Risk Management Department in the Fiscal Services Division located in the Auxiliary Services Center. Any questions regarding work related injury information including first reports of injury, designated physicians work status reports, notification of lost time due to a work related injury or return to work releases can be directed to riskmanagement@cherrycreekschools.org, Sherry Williams (720-554-4644) Christine Baxter (720-554-4617), or Jody Prentice (720-554-4626). The Colorado Workers Compensation Statute is very specific on the timelines for reporting of work related injuries by the employee, as well as by the employer. Fines and penalties can be assessed for late reporting against both the employee and/or the employer. The law requires the injured employee to report the work-related injury in writing within four working days of the accident (see attached Employer s First Report of Injury). We must have the completed First Report of Injury in our third party administrator s office within eight days of the injury and they must file it with the State Division of Workers Compensation within 20 days of the injury to admit liability or deny the claim. We have attached procedures to establish the required process for seeking medical treatment, reporting claims, statutory timelines and forms to be used for work related injuries. We have also included a Workers Compensation Program Employee Information document to assist you in the completion of the First Report of Injury form. This document should give you a general overview of how the workers compensation system operates. If you have questions, or if we can further assist you, please feel free to give one of us a call.
Cherry Creek School District Workers Compensation Program Employee Information Introduction The Colorado Workers Compensation Act (Title 8) establishes that employers, such as Cherry Creek School District, must provide medical care and a scheduled amount of Wage Loss Benefit to employees who sustain an injury or illness arising out of their employment. This obligation can be met either by purchasing insurance or by self-insuring the risk. The District has elected to self-insure this obligation through the Joint School Districts Workers Compensation Self Insurance Pool. The following are instructions for making a claim under the District s Workers Compensation Program and a brief outline of benefits. This information is not meant to be a detailed explanation of the Workers Compensation Statute. If more specific information is desired please contact the Colorado Division of Workers Compensation or the Risk Management Department. Medical Care Medical expenses, including hospital charges, bills from designated physicians, prescriptions, etc. for work related injuries and illness are covered under the District s Workers Compensation Program. Except in cases of extreme emergency, such as life or limb threatening, medical treatment is to be obtained only from one of the medical facilities designated by the District. You may select from the four corporate medical providers listed on the provider list where you want to receive treatment for your work related injury. Follow-up care, after receiving emergency medical treatment, must be provided by one of the designated providers listed on the provider list the next day or as soon as possible. The District has designated Concentra, Rocky Mountain Medical Group, On Point and Workwell Occupational Medicine as the facilities for treatment of work related injuries/illnesses. An Authorization for Medical Treatment form is included that will need to be signed by the building nurse and/or your supervisor or you may use your District ID badge. You will need to bring the form or your ID badge with you to present at the facility you have chosen from the Designated Provider List. In cases of extreme emergency (life or limb threatening), or if you are outside the Denver Metropolitan Area on District related business, go immediately to the nearest emergency medical facility for treatment. Either you or your representative must contact the District s Risk Management Department, Sherry Williams (720-554-4644), Christine Baxter (720-554-4617), or Jody Prentice (720-554-4626), by the following work day to report the injury and select a designated provider. If any employee wishes to receive medical care for a work related injury/disease from his/her personal physician or a provider other than those that have been authorized by our insurance company, it will be at the employee s own expense. Prescription Drug Program Cherry Creek Schools has partnered with Optum to have prescriptions for your work related injury filled at no expense to you. A temporary card will be provided to you at your initial doctor s visit. Authorization cards will be mailed directly to you after your claim has been filed. Simply take the authorization card, along with your prescription, to the nearest participating pharmacy. Optum will bill our workers compensation third party administrator directly.
Wage Loss Benefits Every claim is subject to a three day statutory waiting period. If you lose more than three days of work because of a work related injury or disease, you are entitled to compensation equal to two thirds (66%) of your average weekly wage subject to a maximum figure, which is established and adjusted each year by statute. The District will allow you to use up to three days of your accumulated sick leave days for absence due to a work-related injury, but only if the workers compensation physician takes you off duty and/or restrictions do not allow for return to work. Thereafter, you will receive the statutory workers compensation benefits. In the event you are physically unable to return to the type of work you were doing with the District or in the event you sustain some permanent physical impairment, permanent disability benefits as established by the Colorado Workers Compensation Act may be payable. Mileage Reimbursement Benefits Workers compensation will reimburse you at the statutory rate for trips to and from the doctor and/or physical therapy. Mileage reimbursement request forms are available in each school nurse s office or in the main office of each building. Reimbursement will be made by our workers compensation third party administrator (Sedgwick) after the required forms have been completed and furnished to their office. Claim Denials or Notice of Contest An employer is required to file an admission or denial of liability with the Colorado Division of Workers Compensation within a limited amount of time where more than three days of lost time occurs. You may receive a copy of a form from the adjuster entitled Notice of Contest. This form in most cases means that the adjuster has been unable to review the claim within the time limitations to be able to accept the claim as compensable. In most cases, you will receive an additional form admitting coverage or a letter denying the claim. If the claim is denied, you can either obtain the benefits available to you through the benefits program for medical expenses and lost time or you can request a hearing at the Division of Workers Compensation. Should a question arise concerning a claim you have filed, you can direct your questions to the Risk Management Department or to the adjuster from Sedgwick who is handling your claim.
Cherry Creek School District s Designated Providers List Workwell Occupational Medicine Workwell Occupational Medicine 2550 S. Parker Rd., Suite 150 Aurora, CO 80014 Phone: 720-512-4408 Hours: Monday Friday 8am 5pm Rocky Mountain Rocky Mountain Medical Group 13650 E. Mississippi Ave., Suite 120 Aurora, CO 80012 Phone: 303-280-2882 Hours: Monday Friday 8am 5pm OnPoint OnPoint Occupational & Urgent Care 24300 E. Smoky Hill Rd, Suite 120 Aurora, Co 80016 Phone: 303-341-0410 Concentra Hours: Sunday Saturday 8am 8pm Concentra Tech Center 11877 E. Arapahoe Rd, Suite 100 Centennial, CO 80247 Phone: 303-792-7368 Hours: Monday Friday 8am 6pm Concentra Greenwood Village 8200 E Belleview, Suite 428C Greenwood Village Phone: 303-741-1166 Hours: Monday Friday 8am 5pm Concentra Aurora South East 10355 E. Iliff Ave. Aurora, CO 80247 Phone: 303-755-4955 Hours: Monday Friday 8am 5pm After Hours and Emergency Care Centennial Medical Plaza 14200 E. Arapahoe Rd. Centennial, CO 80112 After Hours and Emergency Room Only Phone: 303-699-3000 In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected Designated Providers the following day.
Your Responsibilities As an employee of the District you have certain responsibilities in your workers compensation claim. Your responsibilities are as follows: 1. Any work related injury or disease must be reported to your supervisor or building administrator within 48 hours of the occurrence or onset of the disease. This includes those accidents that do not require medical treatment. 2. Written notice of an injury resulting from an accident must be given by you to the Risk Management Department within four working days after the accident. Failure by you to give this written report may result in penalties being imposed against you. 3. If requested by your supervisor, you will assist in the completion of the form entitled Employer s First Report of Injury. This form may be completed by your supervisor and/or their designee. The completed form must be sent to the District s Risk Management Department within four working days of the injury or onset of the disease. 4. If medical treatment is required, you should first be examined by the nearest District nurse. If further medical treatment is necessary, obtain an Authorization for Medical Treatment from the school nurse or supervisor. In accordance with Colorado Revised Statute 8-43-404 (5) (a), you can select from the list of corporate medical providers designated by the District, please see the Cherry Creek Designated Provider List on the previous page. Emergency life and limb threatening treatment should be obtained at the nearest medical facility and all follow-up care needs to be provided at one of the above selected designated providers the following day. 5. The physician will provide you with a copy of the treatment form, which will contain the physician s diagnosis, a release to return to work, any work restrictions, follow-up appointment dates, or time off work requirements. You must return a copy of the doctor s report to your supervisor after each doctor s visit. Subsequent follow up appointments or therapy visits should be recorded as sick/general leave absence. It is your duty and responsibility to keep your supervisor advised on your medical updates and return to work status. 6. Your claim will be adjusted by a person retained by the District s insurance pool. It will be necessary for you to cooperate fully with the adjuster, supply any information required including a signed release and attend any medical or vocational evaluations that are arranged for you. 7. All bills you receive should be forwarded to the Risk Management Department. We will forward the bills to our adjuster for review. If the claim is accepted, bills will be paid based on the Colorado Workers Compensation Fee Schedule. If the claim is denied by the adjuster, you will be required to assume responsibility for the bills yourself or to obtain coverage from your health insurance carrier. 8. If you miss more than three days due to a work related injury, you must complete and file with your supervisor a Leave Request Form. On the fourth day of absence, your supervisor, office manager, or terminal manager will forward a copy of this form to the Benefits Office. Leave request forms can be found in The Backyard at: https://backyard.cherrycreekschools.org/departments/benefits/loa/pages/default.aspx. 9. You must present a written release before you return to work from the designated provider. You cannot return to work until you have a written release from the designated provider.
What Should I Do If I Am Injured At Work? 1. In the case of a serious life or limb-threatening emergency, call 911 or go to any hospital/trauma center! Follow-up care is to be arranged with one of the District s designated medical providers, please see the list of Designated Providers below. 2. If the injury is not a serious emergency, you must contact the designated individual at your facility, complete a First Report of Injury, have your supervisor sign it and submit it to Risk Management. If you choose to be seen by a doctor you must select one of the District s designated medical providers listed below. You are not authorized to see your personal physician for a work related injury. Any costs for care by your personal physician will not be covered by the District s Workers Compensation Program. The Employer s First Report of Injury must be filed through the Risk Management Department in order for your bills to be paid through the District s Workers Compensation Program. FAX the report to 720-554-4641 or email to riskmanagement@cherrycreekschools.org. 3. You will be seen by the District s designated medical providers and be provided follow up care. Risk Management and Sedgwick will monitor your progress throughout your claim. You must select a designated provider from the list provided below: Designated Providers Workwell Occupational Medicine 2550 S Parker Rd., Suite #150 Aurora, CO 80014 720-512-4408 Monday- Friday 8am -5pm Rocky Mountain Medical Group 13650 E. Mississippi Ave, Aurora, CO 80012 303-280-2882 (Near 1-225 & Mississippi) Monday- Friday 8am 5pm On Point Occupational Medicine & Urgent Care 24300 S. Smoky Hill Rd Aurora, CO 80016 303-330-0410 Sunday Saturday 8am-8pm Concentra Tech Center 11877 E. Arapahoe Rd. Suite #100 Centennial, CO 80112 303-792-7368 Monday - Friday 8am - 6pm ********************* Concentra Greenwood Village Concentra Aurora South East 10355 E. Iliff Ave. Aurora, CO 80247 303-755-4955 Monday - Friday 8am - 5pm 8200 E. Belleview Suite #428C Greenwood Village, CO 80111 303-741-1166 (Near 1-25 & Belleview) Monday Friday 8am-5pm In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected designated providers the following day. 4. It is your responsibility to inform the Risk Management Department and your supervisor of your injury as well as keep your supervisor informed of any restrictions given to you by the Designated Provider. 5. Questions? Call Sherry Williams at 720-554-4644, Christine Baxter at 720-554-4617, or Jody Prentice at 720-554-4626. We will help you through your injury and get you back to work!
CHERRY CREEK SCHOOL DISTRICT #5 AUTHORIZATION FOR MEDICAL TREATMENT OR EVALUATION (Bring this document with you to the workers compensation provider s facility.) EMPLOYEE S NAME: DATE OF BIRTH: DATE: I.D. VERIFIED: NOTICE AND ACKNOWLEDGEMENT Cherry Creek School District is self-insured with the Joint School District Workers Compensation Self-Insurance Pool in conjunction with a third party claims administrator, Sedgwick. Your employer contact is: Claims Administrator contact: Risk Management Sedgwick 4850 S. Yosemite Street P.O. Box 14493 Greenwood Village, CO 80111 Lexington, KY 40512-4493 Karyn Fast, Risk Manager Phone: 303-713-6031 Phone: 720.554.4643 Fax: 303-713-6056 Sherry Williams, Risk Management Specialist Phone: 720-554-4644 Christine Baxter, Risk and Opportunity Specialist Phone: 720-554-4617 Jody Prentice, Risk Management Specialist Phone: 720-554-4626 Fax: 720.554.4641 Email: riskmanagement@cherrycreekschools.org NOTICE AND SELECTION OF PROVIDERS I do not want to seek medical treatment at this time. Please put a check mark in the box below for the Designated Provider you choose to see if seeking treatment. Workwell Occupational Medicine 2550 S Parker Rd., Suite #150 Aurora, CO 80014 720-512-4408 Monday- Friday 8am -5pm Rocky Mountain Medical Group 13650 E. Mississippi Ave, Aurora, CO 80012 303-280-2882 (Near 1-225 & Mississippi) Monday- Friday 8am 5pm On Point Occupational Medicine & Urgent Care 24300 S. Smoky Hill Rd Aurora, CO 80016 303-330-0410 Sunday Saturday 8am-8pm Concentra Tech Center 11877 E. Arapahoe Rd. Suite #100 Centennial, CO 80112 303-792-7368 Monday - Friday 8am - 6pm ********************* Concentra Greenwood Village 8200 E. Belleview Suite #428C Greenwood Village, CO 80111 303-741-1166 (Near 1-25 & Belleview) Monday Friday 8am-5pm Concentra Aurora South East 10355 E. Iliff Ave. Aurora, CO 80247 303-755-4955 Monday - Friday 8am - 5pm In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected designated providers the following day. Signature: Date:
MILEAGE REIMBURSEMENT FORM Claim Number: Name: Employer: Cherry Creek School District Address: DATE FROM DESTINATION ROUND TRIP MILES PURPOSE TOTAL MILES: I certify that the statements in the above schedule are true and correct in all respects; that payment of the amounts claimed herein has not and will not be reimbursed to me from any other sources; that travel performed for which reimbursement is claimed was performed by me for medical treatment and that no claims are included for expenses of a personal or political nature or for any other expenses not authorized by workers compensation; and that I actually incurred or paid the operating expense of the motor vehicle for which reimbursement is claimed on a mileage basis. I am aware that I may be prosecuted for fraud if the information I have provided is falsely documented. Signature: Date: Total to be Reimbursed: Miles @.53 (cents) per mile = $ Return to: Sedgwick P.O. Box 14493 Lexington, KY 40512-4493 or Fax: 303-713-6056
WARNING IF YOU ARE INJURED ON THE JOB, WRITTEN NOTICE OF YOUR INJURY MUST BE GIVEN TO YOUR EMPLOYER WITHIN FOUR WORKING DAYS AFTER THE ACCIDENT, PURSUANT TO SECTION 8-43-102(1) AND (1.5), COLORADO REVISED STATUTES. IF THE INJURY RESULTS FROM YOUR USE OF ALCOHOL OR CONTROLLED SUBSTANCES, YOUR WORKERS COMPENSATION DISABILITY BENEFITS MAY BE REDUCED BY ONE-HALF IN ACCORDANCE WITH SECTION 8-42-112.5, COLORADO REVISED STATUTES.
AVISO SI SE LASTIMA EN EL TRABAJO, DEBE DARLE UN AVISO POR ESCRITO A SU EMPLEADOR DENTRO DE CUATRO DÍAS LABORABLES DEL ACCIDENTE, SEGÚN A LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO 8-43-102(1) Y (1.5). SI EL ACCIDENTE RESULTA DEBIDO AL USO DE ALCOHOL O UNA SUSTANCIA CONTROLADA, SUS BENEFICIOS DE LA INCAPACIDAD DE LA COMPENSACIÓN DE LOS TRABAJADORES PUEDEN SER REDUCIDOS POR UN MEDIO EN ACUERDO DE LA SECCIÓN DE LOS ESTATUOS REVISADOS DE COLORADO 8-42-112.5
CHERRY CREEK SCHOOL DISTRICT #5 EMPLOYER S FIRST REPORT OF INJURY Employee s name (First, Middle, Last) Employee ID # Male Female Employee s home phone # ( ) Employee s street address City State Zip code Marital status Married Single Separated Date of Injury Birth Date Employment Status Full time Part time Other Time employee began work a.m. p.m. Date of Hire Occupation & Supervisor Name Injury time a.m. p.m. Nurses Initial Evaluation: Did the injury occur on premises? No Yes Name of Bldg. where Injury Occurred: Last day worked # Of hours worked per day # Of days worked per week Date employer notified Date disability began Date returned to work Initial Treatment (Check One) None School Minor on-site Work Comp Clinic Emergency room Hospital Names of Witnesses to the Injury/Illness: Name: Phone Number: Name: Phone Number: ***Please answer the following questions to further describe the injury: 1. Have you had a Work Comp Injury that involved this body part? No Yes 2. Did this accident aggravate a previous injury? No Yes 3. Have you been injured on the job before? No Yes 4. Was the employee wearing appropriate shoes? No Yes 5. Did the employee fail to use safety devices or obey safety rules? No Yes DESCRIBE WHAT HAPPENED IN DETAIL: What was the employee doing at the time of injury? What object or substance harmed the employee? What body parts are affected? I do not want to seek medical treatment at this time. Please put a check mark in the box below for the Designated Provider you choose to see if seeking treatment. Workwell Occupational Medicine 2550 S Parker Rd., Suite #150 Aurora, CO 80014 720-512-4408 Monday- Friday 8am - 5pm Rocky Mountain Medical Group 13650 E. Mississippi Ave, Aurora, CO 80012 303-280-2882 (Near 1-225 & Mississippi) Monday- Friday 8am 5pm On Point Occupational Medicine & Urgent Care 24300 S. Smoky Hill Rd Aurora, CO 80016 303-330-0410 Sunday Saturday 8am 8pm Concentra Tech Center 11877 E. Arapahoe Rd. Suite #100 Centennial, CO 80112 303-792-7368 Monday - Friday 8am - 6pm ********************* Concentra Greenwood Village 8200 E. Belleview Suite #428C Greenwood Village, CO 80111 303-741-1166 (Near 1-25 & Belleview) Monday Friday 8am-5pm Concentra Aurora South East 10355 E. Iliff Ave. Aurora, CO 80247 303-755-4955 Monday - Friday 8am - 5pm In case of serious injury call 911 or go to any medical facility. Follow up care needs to be provided at one of the above selected designated providers the following day. I understand that I must be seen by one of the above designated Medical Providers for Cherry Creek Schools. I further understand the list of designated medical providers is available from my school nurse, site secretary, the Risk Management Office and the Risk Management website. It is unlawful to provide, false, incomplete, r misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, civil damages and employment disciplinary action. Injured Employee Date Supervisor/Person Notified Date