1 WORKERS COMPENSATION PROCESS CHECKLIST Any employee who sustains a work-related accident/injury must: Report incident immediately to immediate supervisor (or administrator, or site/school designee). Report incident immediately to Company Nurse, at ALL INJURIES MUST BE CALLED IN! Employee will provide all applicable information regarding injury incident to Company Nurse. Company Nurse will generate Incident Report, which VACoRP will use as a basis for the employer s report to the Virginia Workers Compensation Commission. Panel of Physicians and Medical Release Form: The injured employee will be requested to complete the Panel of Physicians and Medical Release Form (joint form). A copy of this form is available on both the Employee Services and Safety and Health Services web pages. Express Scripts Temporary Prescription Card: If the treating physician gives the injured employee a prescription, the injured employee may use the Express Scripts Temporary Prescription Card for their first 15 days, not to exceed 150 pills. With almost 50 pharmacy choices, including all pharmacies in Gloucester, this card will enable injured employees from having any out-of-pocket medication expenses. A copy of this form is available on both the Employee Services and Safety and Health Services web pages. Request medical documentation from treating physician; a copy of this should be faxed to the workers compensation / injury coordinator (Craig Smith Phone: ; Fax: ) as soon as possible following any/all related visit(s) to the doctor or testing/surgery facilities. Additionally, a work note indicating work status (release to return to regular duty, or release to return to modified duty with restriction(s) listed, or restriction from work) must be turned into Employee Services (our fax number is ). The treating physician may fax this paperwork directly to this office. Notify/provide paperwork to immediate supervisor (or administrator); keep them informed. Submit related bills to the workers compensation / injury coordinator (Craig Smith ) for submission to the insurance carrier. The fax number is Submit related receipts for prescriptions (showing name of drug[s]/doctor/date/amount/proof of payment). Submit mileage form for related travel (to/from doctor s office and testing/surgery facilities). Please note that benefits/payments are not guaranteed. Time lost for medical appointments might not be payable. Determinations regarding compensability and coverage are made by the Workers Compensation insurance carrier following a review of the claim, medical notes, etc. Refer to the Work-Related Accident/Injury Leave section of the Staff Leave policy File No. GBDG for additional information. Call the workers compensation / injury coordinator (Craig Smith ) if you have any questions School Year Employee Services & Communications
2 INJURY REPORTING / COMPANY NURSE / WHAT TO DO IF YOU RE INJURED / WC Your safety and the safety of others is the #1 goal of Gloucester County Public Schools in fact, it is a foundational part of Gloucester County Public Schools mission, vision, values, and goals. It is our duty and responsibility to provide for, and contribute to, a safe learning and working environment. Be diligent; be careful; be proactive exercise good common sense at all times please do your part to help prevent accidents within the Gloucester County Public Schools professional learning community especially with slips, trips, and falls. Sometimes, however, accidents do happen. You might slip. You might trip. You might fall. You might get injured in a different manner. What do you do if you think you are injured? What do you do if you know you have been injured? The answer is the same call Company Nurse! Company Nurse is a third-party vendor we utilize for generating the first report of injury; Company Nurse is part of our workers compensation program. Please notify your supervisor as well. Even if the designated person for your school or department is not available to assist you (at the schools it is generally a school nurse or administrative professional in the office; in other departments it is generally the attendance/timekeeper person), please make the call yourself. We will also ask you to sign and date an Approved Panel of Physicians & Medical Release Form which lists the primary and specialist physicians that are on our approved panel for workers compensation matters. Where do I send the medical paperwork that is associated with this workplace injury? All medical, billing, and return to work (RTW) paperwork needs to be forwarded to the attention of Craig Smith in Employee Services & Communications. Please fax (or have the physician fax) the paperwork to Please keep your supervisor informed about your return to work status. If you have any questions about worker s compensation, injury reporting, or COMPANY NURSE, please call me directly at (office) or (cell). For more information/resources regarding worker s compensation, please visit this web page: Departments/EmployeeServicesCommunications/tabid/16531/Default.aspx. Have a safe and enjoyable school year!!!
3 GLOUCESTER COUNTY PUBLIC SCHOOLS WORKERS COMPENSATION APPROVED PANEL OF PHYSICIANS & MEDICAL RELEASE FORM Riverside Urgent Care at Hayes Phone: Fax: George Washington Mem. Hwy. David Justis, MD Bonnie Riportelli, MD Hayes, VA SuChong Weber, MD Raul Rodriguez, MD David Newton, MD Deborah Bostock, MD Lalani McCann, MD Occupational Medicine and Family Practice Phone: Fax: Thimble Shoals Blvd., Suite 102 Roxanne Dietzler, DO Newport News, Virginia Sentara Gloucester Urgent Care Phone: Fax: Sentara Gloucester Medical Arts Building Wendell Poulsen, MD Gerald Packer, MD 5659 Parkway Dr., Suite 100 Gloucester, Virginia TPMG Yorktown (Family Practice) Phone: Fax: Cook Rd. John Bryant, MD Hawes Campbell, III, MD Yorktown, Virginia Ann Marie Campolattaro, MD Carl Lindeman, MD Note: TPMG is the Tidewater Physicians Multispecialty Group THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION. IF FOLLOW-UP CARE IS NEEDED ONCE THE EMERGENCY TREATMENT IS COMPLETED, PLEASE REFER TO THIS PANEL OF PHYSICIANS FORM AND YOUR SELECTION BELOW. I will select a doctor, if needed, from the above panel. I decline to select a doctor from the above panel. I understand that I will have to pay for any medical treatment or doctor s bills, and that I may be denied workers' compensation for any absence based on a disability which is not certified by an approved panel doctor. I hereby authorize Company Nurse, VACo CompCare, the employer, or their representative to be furnished with any information regarding treatment, including work status, diagnosis, prognosis, estimates of disability, recommendations for further treatment, and other related records. This information is to be used for the sole purposes of evaluating and handling this claim, and assuring timely medical care as a result of the incident occurring on or about the date noted below, and for no other purpose now or in the future. Signature of Employee Signature of Employer Date Date WE REQUEST THAT THIS FORM BE COMPLETED AND SUBMITTED, EVEN THOUGH THE EMPLOYEE MAY NOT PLAN TO SEE A DOCTOR. NOTE TO SUPERVISOR OR WORKERS COMPENSATION COORDINATOR: Please have the employee sign and date this release form, even if they don t plan on seeing a doctor right away. Please sign and date this form as a witness. Please fax this form to before sending the original in the Inter-Office Mail to Employee Services. Please ask the employee to forward all medical billing and return-to-work information to our attention in Employee Services. If you have additional questions, please feel free to call Craig Smith at Revised: 12/10/13
4 GLOUCESTER COUNTY PUBLIC SCHOOLS WORKERS COMPENSATION APPROVED PANEL OF SPECIALIST PHYSICIANS PLEASE NOTE: the authorized treating panel physician directs the referral process to the authorized treating specialist physician, which may or may not include one of the physicians noted below. Hampton Roads Orthopedics and Sports Medicine Phone: Fax: Thimble Shoals Blvd., Suite 130 John Aldridge, MD Adrian Baddar, MD Newport News, Virginia Anthony Carter, MD Daniel Cavazos, MD Thomas Fithian, MD Jon Swenson, MD Sentara Orthopedics and Sports Medicine Phone: Fax: Discovery Park Blvd., Suite B Charles Wilhelm, MD Alexander Lambert, MD Williamsburg, Virginia Larry Washburn, MD TPMG Orthopedics Phone: Fax: Tidewater Physicians Multispeciality Group Orthopedics 860 Omni Blvd., Suite 203 Daniel Carr, MD Robert Grant, MD Newport News, Virginia Jeffery Moore, MD Michael Potter, MD Thomas Durbin, MD Lara Quinlan, MD TPMG Orthopedics Phone: Fax: Tidewater Physicians Multispeciality Group Orthopedics 4125 Ironbound Rd., Suite 200 Daniel Carr, MD Jeffery Moore, MD Williamsburg, Virginia Michael Potter, MD Andre Johnson, MD Jim Dallas, MD Lara Quinlan, MD Note: TPMG is the Tidewater Physicians Multispecialty Group All medical billing and return-to-work documentation, as well as questions or inquiries, should be directed to Craig Smith in Employee Services. Our mailing address is: Gloucester County Public Schools Attn: Craig W. Smith / Employee Services 6099 T.C. Walker Road Gloucester, VA Phone: Fax: For additional questions, please feel free to contact Craig Smith at / (804) Revised: 12/10/13
5 Gloucester County Public Schools 6099 T.C. Walker Road Gloucester, VA Em: Ph: (804) Fx: (804) For additional information or questions about this service, please contact Craig Smith at the phone number or address above.
6 HAVE A QUESTION? Please contact Craig Smith Gloucester County Public Schools 6099 T.C. Walker Road Gloucester, VA Em: Ph: (804) Fx: (804) For additional information or questions about this service, please contact Craig Smith at the phone number or address above.
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