Sedgwick Claims Kit Arizona

Transcription

1 Sedgwick Claims Kit Arizona P.O. Box Lexington, KY PHONE FAX FREE

2 Dear Insured: We would like to welcome you as a policyholder of Republic Underwriters Insurance Company. Sedgwick is your Claims Administrator and we are pleased to be able to provide you with workers compensation claims handling services. Please follow the below instructions for filing a new claim and note the claim kit attachment. Where do I report a claim? Phone: (855-7ATLAS7) OR; AtlasGeneralInsurance@sedgwickcms.com OR: Fax: Where do I send my injured employee for medical treatment? Website: Sedgwick Claim Kit Attachments: Employer s First Report of Injury Form Employer s FAQ Workers Report of Injury form Injured Worker Handbook Notice to Employees poster TO BE POSTED IN WORKPLACE Work Exposure to MSRA, TB, Spinal Meningitis TO BE POSTED IN WORKPLACE Work Exposure to Bodily Fluids poster TO BE POSTED IN WORKPLACE Employee Safety and Health Protection poster - TO BE POSTED IN WORKPLACE Authorization for Release and Use of Medical Information Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card Need a loss run? us: Lossruns@atlas.us.com Have more questions? Contact the Atlas Customer Care Sedgwick - One of our friendly Client Services Associates will be happy to assist you. Phone: AtlasTeam@Sedgwickcms.com We appreciate your business and believe that communication is critical for successful claims administration. We encourage you to contact us if you have any questions. P.O. Box Lexington, KY PHONE FAX FREE

3 To Find a Physician sedgwick Conoentra Address Hours Hatfleld Family Medicine Primary care- 595 N. Dobson Rd.Ste 065,Chandler, AZ Chandler Regular:(Mon.- Fri.)8arn - Spm Hatfield Family Medicine Primary care- Gilbert 3331E. Baseline Rd.,Gilbert. AZ Regular:(Mon. Fri.) Sam- 5pm East Mesa 1959 S ValVista Drive Ste.106, Mesa,AZ Regular:(Mon. Fri.) Sam 5pm; PhysicaiTherapy:(Mon. - Fri.) Bam- 5pm; Holiday :(All Holidays) Closed I Mesa 1710 W Southern,Mesa,AZ Regular :(Mon.F ri.) Sam- 6pm(Sat)8am 12pm; PhysicatTherapy :(Mon.- Frl.)8am- 5pm;Holiday :(All Holidays) Closed Hatfield Family Medicine Primary Care- Mesa 220 N. Stapley Or.,Mesa,AZ Regular:(Mon.- Fri.) Bam Spm Hatfield Family Medicine Primary Care - Red Mountain 6810 E.Brown Rd.,Mesa, AZ Regular :(Mon.- Fri.) Bam- Spm Mesa Famliy Medical Center 1345 East McKellips Road Suite los,mesa, AZ85203 Regular :(Mon. Fri.) Sam - Spm Regular:(Mon.- Fri.) 7am 6pm(Sat.) Bam- Peoria N. 83rd Avenue Bldg.8,Suite 148, Peoria,AZ pm; PhysicaiTherapy:(Mon. Fri.) Sam- 5pm; Holid ay :(All Holidays) Closed West 35th and Thomas 3532 W Thomas Road Suite 5,Phoen1x, AZ Regular:(Mon.- Fri.) Sam- Gpm; PhysicaiTherapy :(Mon. -Fri.) Sam Spm; Holiday:(All Holidays) Closed Southwest - 51st and Buckeye 5340 W Buckeye Road Ste. 3,Phoenix,AZ Regular : Mon. Fri.) Bam- 5pm; PhysicaiTherapy: (Mon. Fri.) Sam- 5pm; Holiday :(All Holidays) Closed Regular :(Mon. Fri.) 7am - 7pm(Sat.) Oam - 6pm,(Sun.) loam 4pm;PhysicarTherapy: (Mon.- Fri.) Sam- Spm;Holiday: N Black Canyon Highway,Phoenix,AZ (Independence Day) 7am- 7pm,(Labor Day) Phoenix Metro Center am 7pm Regular: (24/7); Physic:aiTherapy :(Mon E Sky Harbor Circle North Bldg 2 Ste. Fri.) 8am - Spm; Holiday :(All Holidays) 12am Airport Phoenlx 150,Phoenix,AZ am Regula r : (Mon. - Fri.) Sam Spm; PhysicaiTherapy :(Moo.- Fri.) 8:30am - Tempe 950 W Southern Avenue,Tempe,AZ Spm;Holiday:(AllHolidays) Closed Hatfield Family Medicine Primary Care Tempe 1315 w. Southern Ave., Tempe,AZ 852S2 Regular:(Mon. Fri.) Sam- Spm P.O. Box I lexington,ky I PHONE I FAX FREE

4 sedgwick M81 Hours Hou s Monday f 11<1 oy 8 OJ am pm Phoen x AZ Phoenix AZ (602) fax l N 59th Ave G endal AZ (602) t f 11in<1ale u 1 /1 >714 (520) FAX r ourmonday nd y 1 00 am 1U OL 1111 "lltii'iby PM Hours Mond<1y rll < t11rda;ij 00 m P.O.Boxl4159 I Lecington,KV I PHONE $:<!l I FAX I FREE

5 Find a Medical Center I U.S. HealthWorks Medical Group Page 1 ofl Enter your street address, city, state, zip and/or select from a drop down menu. After choosing your Address: I Select from the list below locationls by address or City: I State: to view all locations or by state, click here to narrow state. Zip: I Radius: 25 miles dov.n your selection by Arizona specific services. l,_. Select Service L... Arizona 1. Southwest Phoenix 2010 N. 75th Avenue Phoenix, AZ Phone: (623) Fax: (623) Scottsdale N. Scottsdale Road Scottsdale, AZ Phone: (480) Fax: (480) Sur nse t""dl - ValleyoTage Glenda Sc ale eye Phoenixo T o o M esa South Globe 0 Mountain ochandler V l age Cllsa Grano San Tan V<JIIey 3. Tempe 1626 South Priest Drive Suite 101 Tempe, AZ Phone: (480) Fax: (480) Tucson (West) 1661 W. Grant Rd. Tucson,AZ Phone: Fax: Tucson (East) 888 S Craycraft Rd # 150 Tucson, AZ Phone: (520) Fax: (520) Tucson (North) 2945 W Ina Rd # 103 Tucson, AZ Phone: Fax: P.O. Box I Lexington, KY I PHONE I FAX I FREE

6 Banner Desert Occupational Health Clinic 2225 W.Southern Mesa,AZ Phone Fax Hours: Monday-Friday 7am- 6pm Rian Childers, Clinic Manager Phone: Theresa Ybarra, Case Coordinator Phone: Fax Kim Thomas, Case Coordinator Tech Phone: Barmer Occupational Health Clinics CLINICS AND CONTACTS Appointments call CentralScheduling:(602) All s are formatted Website www Bannerhealth com/occhealth sedgwick Banner Thunderbird OccupationalHealth Clinic Paseo Medical Plaza 5601W. Eugie Ave.,Suite 213 Glendale,AZ Phone Fax Hours: Monday-Friday 7am - 6pm Katheryn Kovacic, Clinic Manager Phone: James Climer, Case Coordinator Phone: Fax: Theresa Ortiz: Case Coordinator Tech Phone: Banner Good Samaritan OccupationalHealth Clinic Edwards Medical Building 1300 N.12th Street,Suite 520 Phoenix,AZ Phone: Fax: Hours: Monday-Friday Sam to 10pm Saturday & Sunday 8am to 4pm Amanda Carranza, Clinic Manager Phone: Veronica Verdugo, Case Coordinator Phone: Rebecca Twyman, Case Coordinator Phone: Banner Estrella OccupationalHealth Clinic Estrella Medical Plaza 9305 west Thomas Road,Suite 235 Phoenix,AZ Phone: Fax: Hours; Monday - Friday 7am - 6pm Joel Gamboa, Clinic Manager Phone: Rebecca Santoro,Case Coordinator Phone: Fax Mobile Services: Cathy Agostino Phone: Banner Gateway OccupationalHealth Clinic 1920 N. Higley Road,Suite 108 Gilbert,AZ Phone: Fax: Hours: Monday-Friday 7arn- 6pm Tammy Fabritz, Clinic Manager Phone: Amy Romero, Case Coordinator Phone: Fax Stacey Warners, Case Coordinator Tech Phone: OccupationalHealth Sales and Customer Service: Sharon Kennedy (480) Kathryn Crippen (480) Carol Divich (480) Vickie Bogardus: (480) Fax: ( ) Billing: Valerie Miller or Sabrina Harbin Phone: Billing Address: P.O. Box Phoenix,AZ MedicalReview Officer Services & Random(s) Program: IsabelBaca On Site Screening Specialist Phone: Fax: P.O.Box I Lexington,KY I PHONE I FAX I FREE

7 Fi nd a Nextcare Urgent Care Clinic in Arizona, Colorado, Ohio, Texas, Virginia & North... Page 4 of 5 E.Thomas Rd. & 16th St. l 2.7 t.11les Away Phone: 1 1l86-:lll1 <1<l!S6 Address: 1101 E Thomas R Su1te A 104 PIJOunix Al8001 Hours: Mon Fn.8:00am mode ght Sat S..n S.OO.m 1ZOO <" d:>g'll c- s hn v rey ( 1.J-fJota CI20U Oooglo.INEGI 63mo Indian SchoolRd.,just W of 48th St. Ptlooe: E indian Sct<>oiRd. Suite 211 Phoenix AZ 05016, Mon. Fn:8.00om -8:00pm Sat 900om 5 OOpm Sun: 2:00pm 8:00pm ' y e> -7 m1 W.McDowell Rd.& 69th Ave 5920wMcCowen Rd Mon. Frt;8:00am 8:00pm Phone:1-1! Phoenix. AZ Sal S..n:8:00em 8:00pm N. Scottsdale Rd.& E. Cuny Rd. e s "" Phone: 14l N Scoi!Sdale Rd $Ute 104 Tempe,AZ l.lon Fri 8:00am 6:00pm Sol Sun s.oaem e:oos>m ----'-- Check-In T With WAHOO Check-In With WAHOO ' ' 1021Tll 43rd Ave.& W.Peoria Av. PhOne; < North 43td Avenue Steoll:l Glen<tale,AZ. &5302 Mon. Fn 8ooam.ailllpm Sat Son: 8:00am - :OOpm Check-In With WAHOO J ' 12.7mi E. Shea Blvd. & 74th St Phone: E Shea Blvd Sulte108 Scottsdale.AZ Mon Fl1, 8.00am.7:00pm Sol Sun:8:00em.4:00pm Check-In with y 12 8 m1 E.Greenway Rd & 32nd St Phone: l E Greenway Rd Suite 102 Phoenix. AZ Mon F S OOem 8:00pm Set Sun:8:00am 8:00pm Check-In with WAHOO '13.1 D Northern Ave.just E of WNOI1hernAve Ilion fn.6:00am1 2:00 ffildrv- Itt Phone: HS58 State 101 Sol SUn 8OOem. 12:00 mid,;ghh Glendole. AZ E.McKellips Rd. & N.nesa or. PhOne:1.-..:381 48:5& 535 E. Mcl<elip5 Rd.SUile 101 Mesa,AZ Mon Fn.e.ooam 8:oopm S &In: 9:;<JOam..S OOpm / Check-In Y withwahoo / Check-In Y_ wlth WAHOO McDowell Rd. & Dysart Rd. Phone: McDowallR0<1d Suite0100 Avoodael,AZ Mon Fri:8.00em.8:00pm Sot.Son:8:00em. 8:00pm _ / Check-In Y wlthwahoo ; I Dobson Rd.& W Fryo Rd Phone S Oob on Rd Sl.ile C 26 Ghandl<>.AZ 8522 Mon Fn:8OOem.12:00 midriglrt Sat Son 8.0Dam -12:00midright Check-In withwanoo '56 ml f y a> 16 8 W Union Hilts Or.& N. 59th Ave. Phone:1-888-:!81 <1858 "" On Tatum Rd.jus t nonh of the 101 Phone: N 59\h Ave Sl.ile 101 GlenoO:e.AZ N Tatum Blvd Stlito 100 PhOenix, AZ MenF n. 8.00em- 8:00pm Sat. Son 8.001!m- 8:00pm Mon. Fn:7:ooam- 7:00pm SatS un: 7:00am 4:00pm Check-In With WAHOO Check-In With WAHOO ' 173m N.98th Avo.& W BellRd. Phone: ' W.BelRoad Suite 105 Sun City,AZ Mon Frt 6:ooam 6:00pm Sal. Sun 8:ooam. 3:00pm Check-In with WAHOO J I" R2cAiinA IM Wut nf Vol Vo IJI 3130 E. Basaline RO Mon fit 8:00am 8:0Dpm P.O. Box Lexington. K Y PHO NE FAX FREE

8 Questions Senior Claims Examiner, Pete Foley Division Claims Manager, Barry Vogt Account Manager, Jean Carey To request loss runs: P.O. Box Lexington, KY PHONE FAX FREE

9 Employer s First Report of Injury P.O. Box Lexington, KY PHONE FAX FREE

10 EMPLOYER S REPORT OF INDUSTRIAL INJURY COMPLETE AND MAIL THIS REPORT WITHIN 10 DAYS FROM NOTICE OF ACCIDENT. FATALITIES MUST BE REPORTED WITHIN 24 HOURS. INDUSTRIAL COMMISSION OF ARIZONA P.O. BOX PHOENIX ARIZONA MAIL TO: (CARRIER NAME & ADDRESS) FOR CARRIER USE ONLY OSHA Case #: FOR OSHA PURPOSES ONLY Employer must, on this form, notify his insurance carrier of every injury or disease suffered by an employee, fatal or otherwise, which is claimed to arise our of or in the course of employment. ARIZONA REVISED STATUTES & RECORDABLE INJURY NON-RECORDABLE INJURY EMPLOYEE 1. LAST NAME FIRST M.I. 2. SOCIAL SECURITY NUMBER * 3. BIRTH DATE 4. HOME ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 5. TELEPHONE 6. SEX MALE FEMALE 7. MARITAL STATUS: SINGLE MARRIED DIVORCED WIDOWED EMPLOYER 8. EMPLOYER S NAME 9. POLICY NUMBER 10. NATURE OF BUSINESS (MANUFACTURING, ETC.) 11. OFFICE ADDRESS (NUMBER & STREET) CITY STATE ZIP CODE 12. TELEPHONE ACCIDENT 13. DATE OF INJURY OR ILLNESS 14. TIME OF EVENT A.M. P.M. 15. TIME EMPLOYEE BEGAN WORK 16. DATE EMPLOYER NOTIFIED OF INJURY A.M. P.M. 17. LAST DAY OF WORK AFTER INJURY 18. DATE OF RETURN TO WORK 19. EMPLOYEE S OCCUPATION (JOB TITLE) WHEN INJURED 20. CLASS CODE ON PAYROLL REPORT 21. EMPLOYEE S ASSIGNED DEPARTMENT 22. DEPARTMENT NUMBER 23. DID INJURY OCCUR ON EMPLOYER PREMISES? YES NO 24. ADDRESS OR LOCATION OF ACCIDENT CITY COUNTY STATE ZIP CODE 25. WHAT WAS THE INJURY OR ILLNESS? Tell us the part of the body that was affected and how it was affected; be more specific than hurt, pain, or sore. Examples: strained back ; chemical burn, hand ; carpal tunnel 26. PART OF BODY INJURED 27. FATAL 28. IF THE EMPLOYEE DIED, WHEN DID THE DEATH OCCUR? DATE OF DEATH YES NO 29. W AS EMPLOYEE TREATED IN AN ROOM? YES N 30. WAS EMPLOYEE HOSPITALIZED O AN IN-PATIENT? YES N O 31. IF VALIDITY OF CLAIM IS DOUBTED, STATE REASON NAME OF PHYSICIAN OR OTHER HEALTH CARE PROFESSIONAL IF HOSPITALIZED, HOSPITAL NAME ADDRESS (STREET, CITY, STATE & ZIP CODE) ADDRESS (STREET, CITY, STATE & ZIP CODE) CAUSE OF ACCIDENT 32. WHAT HAPPENED? Tell us how the injury occurred. Examples: When ladder slipped on wet floor, worker fell 20 feet ; Worker was sprayed with chlorine when gasket broke during replacement ; Worker developed soreness in wrist over time. 33. WHAT OBJECT OR SUBSTANCE DIRECTLY HARMED THE EMPLOYEE? Examples: concrete floor ; chlorine ; radial arm saw. If this question does not apply to the incident, leave it 34. WHAT WAS EMPLOYEE DOING JUST BEFORE THE INCIDENT OCCURRED? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific. Examples: climbing a ladder while carrying roofing materials ; spraying chlorine from hand sprayer ; daily computer key- 35. IF ANOTHER PERSON NOT IN COMPANY EMPLOY CAUSED ACCIDENT, GIVE NAME AND 36. WAS WORKER IN YOUR EMPLOY 37. HOURS PER DAY EMPLOYEE WORKED WHEN INJURED? 38. WAS EMPLOYEE ON OVERTIME WHEN INJURED? 39. NUMBER OF DAYS PER WEEK USUALLY WORKED EMPLOYEE S WAGE DATA YES NO YES NO FROM A.M. P. M. T HRU A.M. P.M. EMPLOYEE COMPANY IF WORK LOSS IS EXPECTED TO EXCEED SEVEN 40. DATE OF LAST HIRE 41. WAS WORKER PAID FOR DAY OF INJURY? 42. WAS EMPLOYEE HIRED FOR PERMANENT IMPORTANT CALENDAR DAYS, COMPLETE ITEMS 40 THRU 47 EMPLOYMENT? YES N O IF Y E S, $ YES NO 43. NUMBER OF MONTHS EMPLOYMENT 44. GIVE EMPLOYEE S WAGE STATUS AS APPLICABLE 45. IS EMPLOYEE FURNISHED VALUE AVAILABLE DURING THE YEAR H O U R D A Y W E E K M O N T H PER LODGING BOARD BOTH $ 46. ACTUAL GROSS EARNINGS OF EMPLOYEE FOR THE 30 CALENDAR DAYS PRECEEDING INJURY (EXAMPLE: IF INJURED APRIL 8, GIVE EARNINGS FROM MARCH 9 THRU APRIL 7) 47. DOES EMPLOYEE CLAIM DEPENDENTS? YES NO IF EMPLOYEE IS PAID OTHER THAN FIXED WEEKLY 48. IF EMPLOYEE EARNS EXTRA PAY FOR OVERTIME, WHAT IS BASIS OF 49. NUMBER OF HOURS OVERTIME CONSIDERED IMPORTANT OR MONTHLY SALARY, COMPLETE ITEMS 48 THRU 55 PAYMENT? NORMAL PER WEEK PER HOUR 50. GROSS WAGES OF EMPLOYEE DURING 12 MONTHS PRECEEDING INJURY 51. IF EMPLOYEE WORKED LESS THAN 12 MONTHS, SHOW GROSS WAGES FROM DATE OF HIRE THROUGH DAY PRIOR TO INJURY FROM THRU $ FROM THRU $ 52. DATE OF LAST WAGE INCREASE IF WITHIN 12 MONTHS PRIOR TO INJURY AUTHORIZED SIGNATURE 53. WAGE BEFORE INCREASE 54. WAGE AFTER INCREASE 55. GROSS EARNINGS FROM DATE OF INCREASE THRU DAY PRIOR TO INJURY $ $ $ DATE AUTHORIZED SIGNATURE TITLE NOTE TO EMPLOYER: 1. Mail one copy to the Industrial Commission within 10 days. 2. Mail one copy to your insurance carrier within 10 days. 3. Keep one copy, for not less than five (5) years, as your supplementary record of injuries required by the Federal Occupational Safety and Health Act of * The mandatory requirement that the social security number be included in forms filed with the Claims Division or Special Fund Division of the Industrial Commission of Arizona is permitted by Section 7(a)(2)(B) of the Federal Privacy Act of 1974, because the Commission s forms, prescribed under the Commission s Rules in existence prior to January 1, 1975, required disclosure of the social security number. The number is used as a means of identifying all the various records in the Claims Division or Special Fund pertaining to an individual. The use of social security numbers is made necessary because of the large number of persons who have similar names and birth dates, and whose identities can only be distinguished by the social security number. Form ICA (Rev. 7/01) THIS FORM APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

11 Notice to Employees MUST BE POSTED P.O. Box Lexington, KY PHONE FAX FREE

12 TO BE POSTED BY EMPLOYER POLICY NUMBER NOTICE TO EMPLOYEES RE: ARIZONA WORKERS COMPENSATION LAW All employees are hereby notified that this employer has complied with the provisions of the Arizona Workers Compensation Law (Title 23, Chapter 6, Arizona Revised Statutes) as amended, and all the rules and regulations of The Industrial Commission of Arizona made in pursuance thereof, and has secured the payment of compensation to employees by insuring the payment of such compensation with: All employees are hereby further notified that in the event they do not specifically reject the provisions of the said compulsory law, they are deemed by the laws of Arizona to have accepted the provisions of said law and to have elected to accept compensation under the terms thereof; and that under the terms thereof employees have the right to reject the same by written notice thereof prior to any injury sustained, and that the blanks and forms for such notice are available to all employees at the office of this employer. * * * * * * * * * * * * * * PARA SER COLOCADO POR EL PATRON NUMERO DE POLIZA AVISO A LOS EMPLEADOS RE: LEY DE COMPENSACION PARA LOS TRABAJADORES DE ARIZONA A todos los empleados se les notifica por este medio que este patron ha cumplido con las provisiones de la Ley de Compensacion para los Trabajadores de Arizona (Titulo 23, Capitulo 6, Estatutos Enmendados de Arizona) tal como han sido enmendados, y con todas las regias y ordenanzas de La Comision Industrial de Arizona hechas en cumplimiento de esta, y ha asegurado el pago de compensacion a los empleados garantizando el pago de dicha compensacion por medio de: Ademas, a todos los empleados se les notifica por este medio que en caso de que especificadamente ellos no rechazen las disposiciones de dicha ley obligatoria, se les considerara bajo las leyes de Arizona de haber aceptado las provisiones de dicha ley y de haber escogido aceptar la compensacion bajo estos terminos; tambien bajo estos terminos los empleados tienen el derecho de rechazar la misma por medio de una notificacion por escrito antes de que sufran alguna lesion, todos los formularios o formas en blanco para tal notificacion por escrito estaran disponibles para todos los empleados en la oficina de este patron. * * * * * * * * * * * * * * KEEP POSTED IN A CONSPICUOUS PLACE. COLOQUESE EN LUGAR VISIBLE.

13 Work Exposure to Bodily Fluids MUST BE POSTED NEXT TO NOTICE TO EMPLOYEES P.O. Box Lexington, KY PHONE FAX FREE

14 WORK EXPOSURE TO BODILY FLUIDS NOTICE TO EMPLOYEES Re: Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS) & Hepatitis C Employees are notified that a claim may be made for a condition, infection, disease, or disability involving or related to the Human Immunodeficiency Virus (HIV), Acquired Immune De fi ci en c y S yndrome (AIDS ), or Hepat iti s C wi thin t he provi si ons of t he Ari zona Wor kers ' Compensation Law, and the rules of The Industrial Commission of Arizona. Such a claim shall include the occurrence of a significant exposure at work, which generally means contact of an employee's ruptured or broken skin or mucous membrane with a person's blood, semen, vaginal f l ui d, s ur gi c a l f l ui d( s ) o r a n y o t he r f l u i d( s ) c on t a i ni n g bl oo d. A N EMPLOY EE MUS T CONSULT A PHYSICIAN TO SUPPORT A CLAIM. Claims cannot arise from sexual activity or illegal drug use. Certain classes of employees may more easily establish a claim related to HIV, AIDS, or Hepatitis C if they meet the following requirements: 1. The employee's regular course of employment involves handling or exposure to blood, semen, vaginal fluid, surgical fluid(s) or any other fluid(s) containing blood. Included in this category are health care providers, forensic laboratory workers, fire fighters, law enforcement officers, emergency medical technicians, paramedics and correctional officers. 2. NO LATER THAN TEN (10) CALENDAR DAYS after a possible significant exposure which arises out of and in the course of employment, the employee reports in writing to the employer the details of the exposure as provided by Commission rules. Reporting forms are available at the office of this employer or from the Industrial Commission of Arizona, 800 W. Washington, Phoenix, Arizona 85007, (602) or 2675 E. Broadway, Tucson, Arizona 85716, (520) If an employee chooses not to complete the reporting form, that employee may be at risk of losing a prima facie claim. 3. NO LATER THAN TEN (10) CALENDAR DAYS after the possible significant exposure the employee has blood drawn, and NO LATER THAN THIRTY (30) CALENDAR DAYS the blood is tested for HIV OR HEPATITIS C by antibody testing and the test results are negative. 4. NO LATER THAN EIGHTEEN (18) MONTHS after the date of the possible significant exposure at work, the employee is retested and the results of the test are HIV positive or the employee has been diagnosed as positive for the presence of HIV, or NO LATER THAN SEVEN (7) MONTHS after the date of the possible significant exposure at work, the employee is retested and the results of the test are positive for the presence of Hepatitis C or the employee has been diagnosed as positive for the presence of Hepatitis C. KEEP POSTED IN CONSPICUOUS PLACE NEXT TO WORKERS' COMPENSATION NOTICE TO EMPLOYEES ICA Form THIS NOTICE APPROVED BY THE INDUSTRIAL COMMISSION OF ARIZONA FOR CARRIER USE

15 Work Exposure to MRSA, Meningitis or Tuberculosis MUST BE POSTED NEXT TO NOTICE TO EMPLOYEES P.O. Box Lexington, KY PHONE FAX FREE

16 WORK EXPOSURE TO METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA), SPINAL MENINGITIS, OR TUBERCULOSIS (TB) Notice to Employees Employees are notified that a claim may be made for a condition, infection, disease or disability involving or related to MRSA, spinal meningitis, or TB within the provisions of the Arizona Workers Compensation Law. (A.R.S ) Such a claim shall include the occurrence of a significant exposure at work, which is defined to mean an exposure in the course of employment to aerosolized MRSA, spinal meningitis or TB bacteria. Significant exposure also includes exposure in the course of employment to MRSA through bodily fluids or skin. Certain classes of employees (as defined below) may more easily establish a claim related to MRSA, spinal meningitis or TB by meeting the following requirements: 1. The employee s regular course of employment involves handling or exposure to MRSA, spinal meningitis or TB. For purposes of establishing a claim under this section, employee is limited to firefighters, law enforcement officers, correction officers, probation officers, emergency medical technicians and paramedics who are not employed by a health care institution; 2. No later than 10 days after a possible significant exposure, the employee reports in writing to the employer the details of the exposure; 3. A diagnosis is made within the following time-frames: a. For a claim involving MRSA, the employee is diagnosed with MRSA within two to ten days of the possible significant exposure; b. For a claim involving spinal meningitis, the employee is diagnosed with spinal meningitis within two to eighteen days of the possible significant exposure; and c. For a claim involving TB, the employee is diagnosed with TB within twelve weeks of the possible significant exposure. Expenses for post-exposure evaluation and follow-up, including reasonably required prophylactic treatment for MRSA, spinal meningitis, and TB is considered a medical benefit under the Arizona Workers Compensation Act for any significant exposure that arises out of and in the course of employment if the employee files a claim for the significant exposure or the employee reports in writing the details of the exposure. Providing post-exposure evaluation and follow-up, including prophylactic treatment, does not, however, constitute acceptance of a claim for a condition, infection, disease or disability involving or related to a significant exposure. Employers must post this notice in a conspicuous place next to the Workers Compensation Notice to Employees. REV. 6/09

17 Employee Safety and Health Protection Poster MUST BE POSTED (8.5 x 14) P.O. Box Lexington, KY PHONE FAX FREE

18 EMPLOYEE SAFETY AND HEALTH PROTECTION The Arizona Occupational Safety and Health Act of 1972 (Act), provides safety and health protection for employees in Arizona. The Act requires each employer to furnish his employees with a place of employment free from recognized hazards that might cause serious injury or death. The Act further requires that employers and employees comply with all workplace safety and health standards, rules and regulations promulgated by the Industrial Commission. The Arizona Division of Occupational Safety and Health (ADOSH), a division of the Industrial Commission of Arizona, administers and enforces the requirements of the Act. As an employee, you have the following rights: You have the right to notify your employer or ADOSH about workplace hazards. You may ask ADOSH to keep your name confidential. You have the right to request that ADOSH conduct an inspection if you believe there are unsafe and/or unhealthful conditions in your workplace. You or your representative may participate in the inspection. If you believe you have been discriminated against for making safety and health complaints, or for exercising your rights under the Act, you have a right to file a complaint with ADOSH within 30 days of the discriminatory action. You are also afforded protection from discrimination under the Federal Occupational Safety and Health Act and may file a complaint with the U.S. Secretary of Labor within 30 days of the discriminatory action. You have the right to see any citations that have been issued to your employer. Your employer must post the citations at or near the location of the alleged violation. You have the right to protest the time frame given for correction of any violation. You have the right to obtain copies of your medical records or records of your exposure to toxic and harmful substances or conditions. Your employer must post this notice in your workplace. The Industrial Commission and ADOSH do not cover employers of household domestic labor, those in maritime activities (covered by OSHA), those in atomic energy activities (covered by the Atomic Energy Commission) and those in mining activities (covered by the Arizona Mine Inspector s office). To file a complaint, report an emergency or seek advice and assistance from ADOSH, contact the nearest ADOSH office: Phoenix: 800 West Washington Phoenix AZ Tucson: 2675 East Broadway Tucson, AZ Industrial Commission web site: Note: Persons wishing to register a complaint alleging inadequacy in the administration of the Arizona Occupational Safety and Health plan may do so at the following address: U.S. Department of Labor OSHA 3221 N. 16th St., Suite 100 Phoenix, AZ Revised 11/01 Telephone:

19 PROTECCION DE SEGURIDAD Y SANIDAD PARA EL EMPLEADO El Acta de Seguridad y Sanidad Ocupacional de 1972 (Acta) provee protección de seguridad y sanidad para los empleados en Arizona. El Acta requiere que cada patron les ofrezca a sus empleados un lugar de empleo libre de riesgos reconocidos que puedan causar daño o muerte. El Acta también requiere que los patrones y empleados cumplan con las normas, y los reglamentos de seguridad y sanidad promulgados por la Comisión Industrial. La ejecución de esta ley se lleva a cabo por la División de Seguridad y Sanidad Ocupacional, un brazo de la Comisión Industrial de Arizona. Como empleado, Ud. tiene los derechos siguientes: Tiene el derecho de notificar a su patron o a ADOSH sobre peligros en su lugar de trabajo. Puede pedir a ADOSH que mantenga su nombre confidencialmente. Tiene el derecho de solicitar una inspección por parte de ADOSH si cree que existen condiciones peligrosas o poco saludables en su lugar de trabajo. Usted o su representante puede participar en la inspección. Si cree que su patron lo ha discriminado por presentar reclamos de seguridad y sanidad o por ejercer sus derechos bajo el Acta, puede presentar una queja a ADOSH durante un plazo de 30 dias después de la acción de discriminación. También tiene protección de discriminación bajo el acta federal de seguridad y sanidad ocupacional y puede archivar una queja con el Secretario de Labor de los Estados Unidos dentro de 30 dias después de la discriminación alegada. Tiene el derecho de ver las citaciones enviadas a su empleador. Su empleador debe colocar las citaciones en un lugar visible en el sítio de la supuesta infracción o cerca de el. Tiene el derecho de protestar el tiempo dado para correjir una violación. Tiene el derecho de recibir copias de su historial médico o de los registros de su exposición a sustancias o condiciones tóxicas y peligrosas. Su empleador debe colocar este aviso en su lugar de trabajo. La ley de seguridad y sanidad en el trabajo no aplica a aquellos patrones que emplean a servicio doméstico, a patrones de actividades marítimas (protejidos bajo OSHA), a patrones en actividades de energia atómica (protegidos bajo la Comisión de Energia Atómica), o a patrones en actividades mineras (protegidos por la Oficina del Inspector de Minas del Estado de Arizona). Para registrar una queja, reportar una emergencia o pedir asistencia de ADOSH, póngase en contacto con la oficina más cercana : Phoenix: 800 West Washington Phoenix AZ Tucson: 2675 East Broadway Tucson, AZ Industrial Commission web site: Nota: Personas que deseen registrar quejas alegando falta de adecuadez en la administración del plan de seguridad y sanidad ocupacional de Arizona pueden dirigirlas a la siguiente dirección: U.S. Department of Labor OSHA 3221 N. 16th St., Suite 100 Phoenix, AZ Revisado 11/01 Teléfono:

20 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Print this page immediately upon receiving notice of injury, fill in the information below and give it to your employee. Injured Employee: 1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys network pharmacy. 2. Give this page to the pharmacist. 3. The pharmacist will fill your prescription at no cost. Prescription Card CARRIER/TPA Sedgwick INJURED WORKER NAME SOCIAL SECURITY NUMBER Please provide directly to Pharmacist EMPLOYER/OTHER ENTITY Atlas General Insurance DATE OF INJURY Notice to Cardholder: This card should be presented to your pharmacy to receive medication for your work-related injury. It is only valid within 30 days of your date of injury. For information regarding the program or to find nearby pharmacies call Attention Pharmacists: Call to establish First Fill benefit eligibility and obtain the ID# for online adjudication of approved benefits for the injured worker. Tmesys is the designated PBM for this patient. Tmesys Pharmacy Help Desk NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information listed above. 3. The Help Desk will provide an ID number for adjudication. (To create a card for your wallet, cut along outer line and fold in half.) Finding a Network Pharmacy Use one of these easy methods to find a network pharmacy: Visit one of the following pharmacy chains: Walgreens Rite Aid Walmart CVS Duane Reade Kroger Publix Safeway Use our pharmacy locator online: Call us: