Office of Human Resources

Size: px
Start display at page:

Download "Office of Human Resources"

Transcription

1 Office of Human Resources (814) The Pennsylvania State University Workers Compensation 410 James M. Elliott Building University Park, PA Please have the employee complete this Workers Compensation Signature Packet as soon as an injury report is completed using our online first report of injury system. 1. Workers Compensation Employee Notification Form 2. Employee Description of Injury Form 3. Workers Compensation Information Sheet 4. Workability Form (Form to be used when seeking medical treatment) 5. Medical Records Release Authorization 6. TMESYS Pharmacy Program 7. Steps to WC Brochure at Penn State Please return signed documents to: Office of Human Resources Workers Compensation Department 410 James M. Elliott Building University Park, PA Phone: (814) Fax: (814) Penn State is committed to affirmative action, equal opportunity and the diversity of its workforce.

2

3

4 EMPLOYEE DESCRIPTION OF INJURY FORM Date of injury: Date injury was reported: Time: AM/PM Reported to PSU ID # Name of Injured Person (Please Print): Address: Phone Number(s) Date of Birth: Male Female Type of Injury: Body Part(s) affected Details of injury 1. Please describe in your own words how the injury occurred. Include specific details such as equipment used, tools, etc. (Please Print) 2. Please describe where the injury occurred and what activity you were performing when the injury occurred. (Please Print) (Continue on the back of this form to add additional details.) Witness to the injury: Name Contact Number Signature of Employee Date: MAIL COMPLETED FORM PROMPTLY TO PENN STATE WORKERS COMPENSATION, 410 JAMES M. ELLIOTT BUILDING, UNIVERSITY PARK, PA For Workers Compensation Use Only: Claim Number An Equal Opportunity University OHR 3/10

5 WORKERS COMPENSATION INFORMATION To All Employees: The Workers Compensation law provides some replacement wages and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. Employers are required to post the name of the company responsible for paying workers compensation benefits in a prominent and easily accessible place; including areas used for the treatment of injured employees or for the administration of first aid. Penn State s Workers Compensation coverage is provided through the Sedgwick. You should report immediately any injury or work-related illness to your supervisor or human resources representative. Your benefits could be delayed or denied if you do not notify your supervisor or human resources representative immediately. If your claim is denied by Sedgwick, then you have the right to request a hearing before a Workers Compensation Judge. The Bureau of Workers Compensation cannot provide legal advice. However, you may contact the Bureau of Workers Compensation for additional general information at: Bureau of Workers Compensation 1171 South Cameron Street, Room 103 Harrisburg, Pennsylvania Telephone No. within Pennsylvania: Telephone No. outside of this Commonwealth: TTY (for hearing and speech impaired only) pa keyword: workers comp. In addition you can contact your human resources representative or the University s Workers Compensation Office ( ) if you have any questions about Penn State s policies. Also attached to this sheet is a complete list of panel physicians and medical providers for your reference. EMPLOYEE SIGNATURE: DATE: EMPLOYEE NAME (PRINTED): EMPLOYER REPRESENTATIVE: DATE:

6 OCCUPATIONAL MEDICINE The Pennsylvania State University Office of Human Resources 1850 East Park Avenue, Suite 310 State College, PA Telephone: (814) Fax: (814) WORKABILITY Clinic: Employee Name: Provider Phone No. PSU ID #: Chief Complaint: Date of Service: Diagnosis: Date of Injury: Type of Visit: Initial Follow-Up Date of 1 st Treatment: Work/Visit Instructions: The following written instructions have been discussed and given to the patient. Work Status: Released on. May return to work without restrictions on. Unable to work. May return to work with the following restrictions on. No use of left/right No lifting Limited use of left/right Weight limit lbs. Limited standing/walking Sitting work only Limited bending/twisting No driving Limited squatting/kneeling Limited Rigorous Grasping Other Referrals: Follow-up: PLEASE FAX A COPY OF THIS FORM TO PENN STATE OCCUPATIONAL MEDICINE AT (814) A Penn State University Workability Form has been provided to me. I have read and understand the visit instructions. I have been instructed to contact my Supervisor today and provide him/her with a copy of this form. I authorize Penn State Occupational Medicine to receive complete medical information from the above Provider. Patient Signature: Date: Signature of Health Care Provider Print Name of Health Care Provider Penn State is committed to affirmative action, equal opportunity and the diversity of its workforce.

7 AUTHORIZATION FOR RELEASE AND USE OF MEDICAL INFORMATION I authorize each of the parties identified below to use and disclose any and all of my individually identifiable medical or health information, as d e s c r i b e d b e l o w, fo r p u r p o s e s o f a d m i n i s t e r i n g m y c l a i m. I u n d e r s t a n d t h a t t h e i n fo r m a t i o n a b o u t m e that I authorize to be used or disclosed may be redisclosed in accordance with the terms of this Authorization by the recipient thereof and may no longer be protected by federal or state privacy laws or regulations. I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means, including written or telephonic communications or by direct interview, whether or not I am present during, or notified of such communications, and I hereby authorize Sedgwick Claims Management Services, Inc., my employer and their representatives and agents ("Sedgwick CMS") to initiate and conduct such communications whether or not I am present or have received notice thereof. 1. What Information is covered by this Authorization? This authorization applies to all medical, health, psychological, and/or psychiatric information, records and reports, including information regarding pre-existing health or medical conditions or illnesses (a) that are in existence while this authorization is valid (see Item 3) and (b) that are related to my workers compensation claim. My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results, x-ray reports, and records received from other health care providers. If directly related to my claimed condition or illness, this information may include the following, Please check yes or no and initial: HIV test results, HIV or AIDS information. YES NO Initial here Psychiatric information. YES NO Initial here Information related to drug or alcohol abuse. YES NO Initial here The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 'Genetic information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. 2. Who may disclose and receive Information under this Authorization? A. I authorize Sedgwick, my Employer, and their representatives and agents to communicate directly both orally and in writing with all treating physicians or medical providers of any kind regarding all facts and opinio ns relevant to my workers compensation claim. I authorize any treating physician or other medical provider to communicate directly both orally and in writing with Sedgwick, my Employer, and their representatives and agents, concerning all aspects of my treatment for the illness or injury for which I am receiving or seeking benefits. B. When relevant to my claim, Sedgwick CMS may re-disclose (without my further authorization) any and all of my individually identifiable medical or health information (whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the following, (a) Any person or facility that attends, treats or examines me; (b) Any person or facility that impacts determination of my claim or that coordinates my benefits; (c) My employer and its affiliates and their representatives, independent contractors and service providers that may receive any such information from my employer to the extent permitted by state or federal law; or (d) The Social Security Administration or a social security or vocational rehabilitation vendor. Sedgwick CMS may use my information obtained pursuant to this authorization in any other claim matter that Sedgwick CMS may administer or handle related to me. 3. How Long this Authorization is Valid? This authorization is valid during the duration of my claim(s) and any future related claims, unless a different period is required under applicable federal or state law. 1

8 4. Revocation of this Authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at any time by notifying, in writing, Sedgwick CMS of my revocation and that my revocation shall be effective upon Sedgwick CMS' receipt of my notice of revocation. I also understand that my revocation of this Authorization will not have any effect on any actions taken by Sedgwick CMS before it receives my revocation. 5. Processing of Claims. I understand that this Authorization is generally necessary for the processing of my Workers Compensation claim. Failure to sign this Authorization may impair or impede the processing of my claim. 6. Refusal To Sign. I further understand my health care providers will not condition my treatment, payment, enrollment or eligibility on my refusal to sign this Authorization. I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to inspect the disclosed information at any time. A photocopy of this authorization shall be valid and is to be accepted with the same effect as the original. Signature of Patient or Patient's Representative Printed Name of Patient or Patient s Representative Representative s Relationship to Patient, if applicable Date Signed Patient s Address First Day Absent Date of Birth Witness Sedgwick CMS 01/01/2011 Sedgwick Claims Management Services, Inc. NOTICE OF STATE FRAUD REQUIREMENTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 2

9 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 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: PMSI, Inc. All rights reserved. C1257B SCMS.

10 Tmesys Retail Pharmacy Network* More than 60,000 pharmacies, including large chains and many neighborhood independent pharmacies, meaning that your prescription can be filled at most pharmacies nationwide. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy & Discount Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *List subject to change. This is a partial listing only PMSI, Inc. All rights reserved. C1257B SCMS

11 6 steps to WORKERS COMPENSATION at Penn State REPORT THE INJURY Penn State wants to help you with every step of your recovery. In order for us to do so, your first step should be to notify your supervisor of any work-related injury. Even if you don t think you need treatment. Your claim will be sent electronically to Penn State s Workers Compensation office. 1 Once reported, an insurance adjuster will review and evaluate your claim to determine whether or not you are eligible for Workers Compensation coverage. Your supervisor will provide you with a copy of the following: Your injury report Employee notification form Healthcare Provider Panel list for your area Retail pharmacy program Workers Compensation information sheet Workability form MEDICAL TREATMENT Penn State Workers Compensation insurance pays related medical and surgical expenses for treatment you receive for injuries sustained on the job. 2 If your injury results in an immediate medical emergency, you should seek urgent care at an emergency facility. If your injury results in the need for ongoing medical care, during the first 90 days of treatment you must use a doctor from Penn State s Healthcare Provider Panel. Failure to treat with a Healthcare Provider Panel during that period may result in unpaid medical expenses. COMMUNICATE 3 Effective communication is essential for all parties involved in the Workers Compensation process. You should remain in contact with your Human Resources Representative, supervisor, and insurance adjuster. You can also call Penn State s Workers Compensation office. PRESCRIPTION COVERAGE 4 Penn State provides a convenient system for you to obtain prescription drug coverage for your work-related injury with no out of pocket expense. The retail pharmacy program is available at many major pharmacies such as CVS, Giant, and Rite Aid. Penn State Office of Human Resources Employee Benefits Workers Compensation 410 James M. Elliott Building University Park, PA FAX RECOVERY Recovery from some injuries may require you to be placed on restricted job duty. A doctor s note placing you on restricted job duty or taking you off of work is required. If your department is unable to accommodate your restrictions or you are medically restricted from performing your job responsibilities, you may be entitled to lost-time wage replacement payments. 5 6 RETURN TO WORK In order to return to work safely, you must provide a doctor s note to your supervisor and Human Resources Representative confirming your release to work. This publication is available in alternative media on request. Penn State is committed to affirmative action, equal opportunity, and the diversity of its workforce. This is a summary of your Workers Compensation benefits. Official policy guidelines supercede this document. BSO Limitless Opportunities Office of Human Resources

CIGNA S RETAIL PHARMACY DIRECTORY FOR 90-DAY PRESCRIPTIONS

CIGNA S RETAIL PHARMACY DIRECTORY FOR 90-DAY PRESCRIPTIONS CIGNA S RETAIL PHARMACY DIRECTORY FOR 90-DAY PRESCRIPTIONS Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam Offered by: Cigna Health and Life Insurance Company,

More information

pharmacy Directory for 90-day prescriptions

pharmacy Directory for 90-day prescriptions Cigna s retail pharmacy Directory for 90-day prescriptions Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam Offered by: Connecticut General Life Insurance Company

More information

pharmacy Directory Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam

pharmacy Directory Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam pharmacy Directory Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam 589901 j 02/13 Offered by: Connecticut General Life Insurance Company or Cigna Health and

More information

Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using:

Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using: Please have the employee complete this Workers Compensation Signature Packet upon submission of an injury report using: Online system link located at http://ohr.psu.edu/workers-compensation/ or Call Center

More information

PHARMACY DIRECTORY. Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam

PHARMACY DIRECTORY. Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam PHARMACY DIRECTORY Participating pharmacies in the United States, the U.S. Virgin Islands, Puerto Rico and Guam Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company

More information

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN

LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN LOS ANGELES UNIFIED SCHOOL DISTRICT POLICY BULLETIN TITLE: Workers Compensation Claims Reporting ROUTING NUMBER: ISSUER: Ref-1279.1 Enrique G. Boull t, Chief Operating Officer Office of the Chief Operating

More information

Sedgwick Claims Kit Pennsylvania

Sedgwick Claims Kit Pennsylvania Sedgwick Claims Kit Pennsylvania P.O. Box 14779 Lexington, KY 40512 Toll Free: 866-738-9201 Fax: 859-280-3275 Dear Insured: We would like to welcome you as a policyholder of Southern Insurance Company.

More information

Sedgwick Claims Kit South Carolina

Sedgwick Claims Kit South Carolina Sedgwick Claims Kit South Carolina P.O. Box 14779 Lexington, KY 40512 Toll Free: 866-738-9201 Fax: 859-280-3275 Dear Insured: We would like to welcome you as a policyholder of Southern Insurance Company.

More information

EXPRESS SCRIPTS PHARMACY DIRECTORY

EXPRESS SCRIPTS PHARMACY DIRECTORY ALABAMA BRUNO'S SOUTHERN FAMILY MARKET ALASKA CARRS PHARMACY ARIZONA FRY'S PHARMACY ARKANSAS HARPS PHARMACY PRICE CUTTER PHARMACY CALIFORNIA BEL AIR PHARMACY BIOSCRIP PHARMACY HORTON & CONVERSE PHARMACY

More information

COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT

COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT COUNTY OF ALLEGHENY EMPLOYEE ACCIDENT REPORT Revised 05/13/14 Section 1: Identification Information Completed by Employee (Supervisor should verify that information is correct.) Employee Name Last First

More information

MEMBER GUIDE AMERICARD

MEMBER GUIDE AMERICARD AccessOne Consumer Health, Inc. a Discount Medical Plan Organization MEMBER GUIDE AMERICARD MEMBER SERVICES 1840 W 49th Street Hialeah, Florida 33012 305-817-4261 IF YOU ARE UNHAPPY The plan is here to

More information

Office of Physical Plant

Office of Physical Plant Office of Physical Plant The Pennsylvania State University Physical Plant Building University Park, PA 16802-1118 Please have the employee complete this Workers Compensation Signature Packet as soon as

More information

Multi-state claims services

Multi-state claims services workers compensation Multi-state claims services Welcome to SFM, your workers compensation insurer. Important information for SFM policyholders with business locations outside Minnesota, Iowa, Nebraska,

More information

pharmacy directory UnitedHealth Rx for Groups Virgin Islands

pharmacy directory UnitedHealth Rx for Groups Virgin Islands UnitedHealth Rx for Groups pharmacy directory This directory provides a list of UnitedHealth Rx for Groups plan's network pharmacies by county for the territory of. All network pharmacies are not listed

More information

Sun Life Assurance Company of Canada

Sun Life Assurance Company of Canada Long Term Disability Claim Packet - Claimant Instructions for the Claimant Please mail all documents 4-6 weeks before the end of your elimination period. Please make sure to initiate the Long Term Disability

More information

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502 P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 DISABILITY CLAIM FORM INSTRUCTIONS Enclosed is a claim form required in order to process disability payments on your loan. It is important that all questions

More information

CHEROKEE COUNTY BOC. Workers Compensation Accident Report Packet

CHEROKEE COUNTY BOC. Workers Compensation Accident Report Packet CHEROKEE COUNTY BOC Workers Compensation Accident Report Packet Cherokee County Board of Commissioners Human Resources Department 1130 Bluffs Parkway Phone: 678-493-6020 ~ Fax:678-493-6021 Dear Employee,

More information

*87503* Group Insurance. Group Life Claim for Total Disability Benefits Employee Statement

*87503* Group Insurance. Group Life Claim for Total Disability Benefits Employee Statement Group Life Claim for Total Disability Benefits Employee Statement Instructions to file a Claim for Group Life Insurance Coverage for Total Disability 1. Complete all sections of the Employee Statement

More information

Managed Care Program

Managed Care Program Summit Workers Compensation Managed Care Program KENTUCKY How to obtain medical care for a work-related injury or illness. Welcome Summit s workers compensation managed-care organization (Summit MCO) is

More information

City of Los Angeles Disability Insurance Claim Packet Instructions

City of Los Angeles Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Work-related accident/injury procedures

Work-related accident/injury procedures PLEASANT VALLEY SCHOOL DISTRICT Work-related accident/injury procedures If a co- worker is injured and unable to drive themselves and a family member can not be reached, DO NOT transport them to a doctor

More information

Occupational Injury / Illness Report

Occupational Injury / Illness Report Occupational Injury / Illness Report This report must be completed whenever a Franklin & Marshall employee, including a student worker, is injured or becomes ill during the course of his/her employment

More information

Helpful Hints Regarding Your Claim

Helpful Hints Regarding Your Claim Short-term Disability Claim Form Instructions EPIC s Short Term Disability Claim Form has three sections you (the employee), your employer, and your attending physician(s) must each complete your corresponding

More information

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. The Standard Benefit Administrators. How To Apply For Benefits

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. The Standard Benefit Administrators. How To Apply For Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

The forms must be completed by a qualified person and signed with their occupational title as per its respective form.

The forms must be completed by a qualified person and signed with their occupational title as per its respective form. Your ability to work and generate income is your greatest asset. If a disability ever left you unable to work, a combination of increased expenses and loss of income could create financial difficulties.

More information

Accident Claim Filing Instructions

Accident Claim Filing Instructions Accident Claim Filing Instructions Page One Filing Instructions Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which includes the date of service,

More information

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502

AMERICAN NATIONAL INSURANCE COMPANY CREDIT INSURANCE DIVISION P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 800-899-6502 P. O. BOX 696785 * SAN ANTONIO, TEXAS 78269-6785 CREDIT LIFE CLAIM FORM INSTRUCTIONS Enclosed is a form required to process a claim for credit life benefits. It is important that all questions be fully

More information

SI 2047-643383 1 of 6 (12/04)

SI 2047-643383 1 of 6 (12/04) Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Aetna Medicare has Solutions to Help You Save on Prescriptions

Aetna Medicare has Solutions to Help You Save on Prescriptions Aetna Medicare has Solutions to Help You Save on Prescriptions Information Booklet Aetna Medicare Rx SM Plan Enrolling is Easy Eligibility Just like the Original Medicare Plan, you must meet certain federal

More information

Short Term Disability Claim Statement

Short Term Disability Claim Statement P.O Box 19721, Irvine, CA 92623-9721 EMPLOYER STATEMENT To be completed by the Employer on behalf of the employee. Please print or type. Attach separate sheet if necessary. Short Term Disability Claim

More information

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits

Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim. How To Apply For Benefits Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

MAIL TO: AIG Benefit Solutions P.O. Box M, Beattyville, KY 41311 FAX: (888) 598-0575

MAIL TO: AIG Benefit Solutions P.O. Box M, Beattyville, KY 41311 FAX: (888) 598-0575 Application for Disability Benefits PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF YOUR CLAIM. INSTRUCTIONS: INSURED: COMPLETE PART I, SIGN AND THE AUTHORIZATION FOR RELEASE

More information

STATEMENT OF RECOVERY OR RETURN TO WORK

STATEMENT OF RECOVERY OR RETURN TO WORK STATEMENT OF RECOVERY OR RETURN TO WORK DISABILITY INCOME CLAIM INSTRUCTIONS (PLEASE DETACH THIS NOTICE BEFORE MAILING AND KEEP FOR FUTURE REFERENCE) Please answer all questions on the Member Statement

More information

The Long Term Disability Benefits application includes claim forms and an Authorization.

The Long Term Disability Benefits application includes claim forms and an Authorization. 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 be filled

More information

Humana short-term income protection claim form

Humana short-term income protection claim form Humana short-term income protection claim form 1-866-836-6144 Instructions Please read and follow the instructions carefully. 1. If this is the initial claim for benefit payments for this disability, please

More information

WORKER S COMPENSATION TREATMENT AUTHORIZATION FORM

WORKER S COMPENSATION TREATMENT AUTHORIZATION FORM 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

More information

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING ACCIDENT AND HEALTH CLAIMS If you are filing for the medical expense benefit only under your accident policy, a claim form may not be needed

More information

Continued Dependent Life Insurance for a Disabled Child Instructions

Continued Dependent Life Insurance for a Disabled Child Instructions Continued Dependent Life Insurance Instructions Your application for consists of four forms. Every space should be filled in to avoid delay in processing your application. If a section does not apply,

More information

All University Employees. Workers Compensation Manager WORK-RELATED INJURY PROCEDURES

All University Employees. Workers Compensation Manager WORK-RELATED INJURY PROCEDURES TO: FROM: SUBJECT: All University Employees Diane Biddle Workers Compensation Manager WORK-RELATED INJURY PROCEDURES The procedure involving work-related injuries requires the injured employee to select

More information

Sun Life Insurance and Annuity Company of New York Short Term Disability Claim Packet

Sun Life Insurance and Annuity Company of New York Short Term Disability Claim Packet 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

More information

American Income Partners is not insurance.

American Income Partners is not insurance. Basic Program Discounts Eye Care Plan Hearing Plan Prescription Drug Plan Chiropractic Plan Gold Program Discounts Basic Program Discounts Dental Plan Vitamins & Nutritional Supplements Hotel & Car Rental

More information

Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012

Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012 Supervisors Workers' Compensation Injury Reporting Procedure Updated January 1, 2012 Call for medical response immediately if the injury is serious Worry about the forms later 1. If the injury is not an

More information

Disability Insurance Claim Packet Instructions

Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

DISABILITY CLAIM FORM

DISABILITY CLAIM FORM ACE American Insurance Company PROOF OF LOSS Mail to: ACE American Insurance Company Name of Group: UNIVERSITY OF CALIFORNIA P.O. Box 15417 Wilmington, DE 19850 800-336-0627 or 302-476-6194 Policy Number:

More information

DATE OF BIRTH / / CITY. WHAT IS YOUR OWNERSHIP PERCENTAGE? % SPECIALTY (if applicable)

DATE OF BIRTH / / CITY. WHAT IS YOUR OWNERSHIP PERCENTAGE? % SPECIALTY (if applicable) INSURED'S ADDRESS (Home Address) Leaders Life Insurance Company Bloomfield, CT 06002 (888) 342-7979 PLEASE ANSWER ALL QUESTIONS FULLY AS THIS WILL HELP EXPEDITE THE EVALUATION OF YOUR CLAIM. INSTRUCTIONS:

More information

Mailing Address: 711 High Street Des Moines, IA 50392-0410

Mailing Address: 711 High Street Des Moines, IA 50392-0410 Mailing Address: 711 High Street Des Moines, IA 50392-0410 Principal Life Insurance Company Disability Claim Notice Instructions For Filing A Claim Please indicate the type of policy and the policy(ies)

More information

Virginia Association of Counties Group Self Insurance Risk Pool Disability Insurance Claim Packet Instructions

Virginia Association of Counties Group Self Insurance Risk Pool Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim We realize that being disabled is difficult. Even though you are unable to work, your financial obligations do not go away. To help you through these

More information

WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS)

WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS) WORKERS COMPENSATION EMPLOYEE S NOTICE OF INJURY (COMPLETE ALL ITEMS) EMPLOYEE S NAME: (last) (first) EMPLOYEE S ADDRESS: (no.) (street) (city) (state) (zip) TELEPHONE: Home: Work: SOCIAL SECURITY NO.

More information

The Howard County Public School System Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim

The Howard County Public School System Disability Insurance Claim Packet Instructions. Your Disability Benefit Claim Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

To file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696.

To file a claim: If you have any questions or need additional assistance, please contact our Claim office at 1-800-811-2696. The Accident Expense Plus policy is a financial tool that helps cover high deductibles, co-pays and other expenses not covered by your primary major medical plan. This supplemental plan reimburses you

More information

UNIVERSITY OF PITTSBURGH WORKERS COMPENSATION INFORMATION

UNIVERSITY OF PITTSBURGH WORKERS COMPENSATION INFORMATION UNIVERSITY OF PITTSBURGH WORKERS COMPENSATION INFORMATION To All Employees: The workers compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care,

More information

TOTAL AND PERMANENT DISABILITY BENEFITS APPLICATION

TOTAL AND PERMANENT DISABILITY BENEFITS APPLICATION 8403 Colesville Road Silver Spring, MD 20910 Phone: (202) 682-6768 Fax: (202) 962-2939 PLEASE PRINT Instructions 1. 2. 3. The member must complete all questions on the application where indicated or his/her

More information

Disability Insurance Claim Packet Instructions

Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

For use with policies issued by Provident Life and Accident Insurance Company

For use with policies issued by Provident Life and Accident Insurance Company For use with policies issued by Please mail or fax this form to: The Benefits Center P.O. Box 100158, Columbia, SC 29202-3158 This form must be completed by the Attending Physician and the Employee, and

More information

Accidental Dismemberment Insurance Claim Form

Accidental Dismemberment Insurance Claim Form State of Florida Account Participating Agencies and Departments Payroll Deduction Code 262 Mail To: Cigna P.O. Box 22328 Pittsburgh, PA 15222-0328 1-800-238-2125 Toll Free Claims administered by Cigna

More information

State of Nevada Public Employees Benefits Program (PEBP) Short Term Disability Insurance Claim Packet Instructions

State of Nevada Public Employees Benefits Program (PEBP) Short Term Disability Insurance Claim Packet Instructions Claim Packet Instructions Your Disability Benefit Claim This packet contains the forms necessary to apply for disability benefits. It also addresses common questions about Disability claims. Please save

More information

Voluntary Disability Benefits

Voluntary Disability Benefits Voluntary Disability Benefits Enclosed you will find a disability packet that will provide information to assist you in filing for disability benefits through The Claremont Colleges Voluntary Disability

More information

Name of Employer Group Report # Sub-Code # (Sub-Division) Sub-Point # (Branch) Research Foundation for Mental Hygiene, Inc.

Name of Employer Group Report # Sub-Code # (Sub-Division) Sub-Point # (Branch) Research Foundation for Mental Hygiene, Inc. DISABILITY CLAIM FOR ACCIDENT & SICKNESS (A&S)/ SHORT TERM DISABILITY (STD)/SALARY CONTINUANCE Instructions for completing the claim form: 1. Complete all applicable areas of the claim form. Please print

More information

NAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident

NAME (First, Middle, Last) Social Security Number Date of Accident (Month-Day-Year) Time of Accident FIRST REPORT OF INJURY OR ILLNESS RECEIVED BY CLAIMS-HANDLING ENTITY SENT TO DIVISION DATE DIVISION RECEIVED DATE FLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance

More information

Self-Insured Injury Reporting PACKET. CareWorksUSA

Self-Insured Injury Reporting PACKET. CareWorksUSA Self-Insured Injury Reporting PACKET CareWorksUSA IMPORTANT NOTICE FOR WORKPLACE INJURIES In the event of a work-related injury, please see one of the medical providers recommended by your employer listed

More information

Sun Life Assurance Company of Canada

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

More information

For use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries:

For use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries: CLAIM FOR INCOME PROTECTION BENEFITS The Benefits Center, P.O. Box 9500, Phone: 800.858.6843 Fax: 800.447.2498 For use with policies issued by the following UnumProvident Corporation [ UnumProvident ]

More information

Managed Care Program

Managed Care Program Summit Workers Compensation Managed Care Program FLORIDA How to obtain medical care for a work-related injury or illness. Welcome The Summit workers compensation managed-care arrangement (Summit MCA)

More information

You also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information.

You also may have purchased the Hospital Cash Rider and/or the Disability Income Benefit Rider. Refer to your policy for detail information. Your Emergency Care policy is supplemental insurance to help cover the additional expenses associated with an accidental injury. An Accident is defined as an unforeseen occurrence of an event, which results

More information

Leaders Life Insurance Accident Claim Filing Instructions

Leaders Life Insurance Accident Claim Filing Instructions Leaders Life Insurance Accident Claim Filing Instructions Page One Filing Instructions: Complete the appropriate sections of the claim form (page 2) Attach an itemized billing from your provider which

More information

For use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries:

For use with policies issued by the following UnumProvident Corporation [ UnumProvident ] subsidiaries: CLAIM FOR INCOME PROTECTION BENEFITS Glendale Customer Care Center, 655 North Central Ave., Suite 800, Phone: 877.851.7637 Fax: 877.851.7624 For use with policies issued by the following UnumProvident

More information

The Long Term Disability Benefits application includes claim forms and an Authorization.

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

More information

The Long Term Disability Benefits application includes claim forms and an Authorization.

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

More information

Short-Term Disability Income Benefit. Employee s Statement

Short-Term Disability Income Benefit. Employee s Statement Short-Term Disability Income Benefit Employee s Statement Employee s Statement Short Term Disability Income Benefits This guide contains the forms you need to apply for disability benefits and some important

More information

Accident Claim Filing Instructions

Accident Claim Filing Instructions Accident Claim Filing Instructions The offering Company(ies) listed below, severally or collectively, as the content may require, are referred to in this authorization as We or Humana. Life, Specified

More information

Life Insurance Claim Requirements

Life Insurance Claim Requirements Life, AD&D, Living/Accelerated Benefit Claim Form Instructions Section A: Section B: Section C: Section D: Section E: Section F: General Information to be completed by the employer s authorized representative.

More information

For use with policies issued by the following Unum Group [ Unum ] subsidiaries:

For use with policies issued by the following Unum Group [ Unum ] subsidiaries: For use with policies issued by the following Unum Group [ Unum ] subsidiaries: Unum Life Insurance Company of America Provident Life and Accident Insurance Company The Paul Revere Life Insurance Company

More information

GROUP DISABILITY CLAIM APPLICATION SEND TO:

GROUP DISABILITY CLAIM APPLICATION SEND TO: GROUP DISABILITY CLAIM APPLICATION SM Short Term Disability (STD) SEND TO: P.O. BOX 9461 PORTLAND, ME 04104-5056 TEL: (877) 565-2437 FAX: (800) 293-4781 Long Term Disability (LTD) SEND TO: P.O. BOX 9461

More information

MoDOT & Patrol Employees Retirement System MPERS Disability Benefits Claim Packet Instructions

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

More information

NOTIFICATION OF INJURY

NOTIFICATION OF INJURY NOTIFICATION OF INJURY This Notification of Injury Form is to be used for accident medical claims. **Note: The SAI claim form (Parts A & B) should be submitted to Loomis (address on next page) as soon

More information

Sun Life Assurance Company of Canada

Sun Life Assurance Company of Canada SunAdvisor Claim Packet Section B: Attending Physician s Statement 1 Information About the Patient Please print clearly Return to: SunAdvisor Fax: (781) 304-5519 The patient is responsible for any costs

More information

Group/Association - Total and Permanent Disability / Waiver of Premium

Group/Association - Total and Permanent Disability / Waiver of Premium Group/Association - Total and Permanent Disability / Waiver of Premium Connecticut General Life Insurance Company Life Insurance Company of rth America CIGNA Life Insurance Company of New York FRAUD WARNING:

More information

GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE

GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE 1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code) 4. Street Address & Mailing Address 5. City 6.

More information

Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis.

Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis. Your Critical Care policy is supplemental health insurance to help cover the additional expenses associated with a critical illness diagnosis. The Critical Care Benefit is a one time lump sum payment.

More information

ADA-Sponsored Disability Income Protection Plan Application for Insurance

ADA-Sponsored Disability Income Protection Plan Application for Insurance Members Insurance Plans ADA-Sponsored Disability Income Protection Plan Application for Insurance IPWS15 Read all forms Complete sections 1 thru 9 Mail or Fax ALL completed forms Questions? 866.607.5334

More information

A Guide for Successfully Completing the Group Short Term Disability Claim Form

A Guide for Successfully Completing the Group Short Term Disability Claim Form A Guide for Successfully Completing the Group Short Term Disability Claim Form Mutual of Omaha appreciates the opportunity to provide you with valuable income protection. We rely on the information you

More information

1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code)

1. Full Name (last, first, middle initial) 2. Social Security Number 3. Phone Number (include area code) GROUP SHORT-TERM DISABILITY STATEMENT OF EMPLOYEE (BENEFITS MAY BE DELAYED IF CLAIM FORM IS NOT FULLY COMPLETED) Please sign this page and the authorization on page two of this form to avoid delays in

More information

Workers Compensation Program Employee Information Packet

Workers Compensation Program Employee Information Packet Workers Compensation Program Employee Information Packet The information included in this packet will become important to you in the event that you seek medical attention or lose time from work due to

More information

For use with policies issued by Provident Life and Accident Insurance Company

For use with policies issued by Provident Life and Accident Insurance Company For use with policies issued by Please mail or fax this form to: Chattanooga Benefits Center P.O. Box 12030 Chattanooga, TN 37401-3030 Toll free: 800.633.7479 Fax: 423.755.3009 or 800.494.4516 This form

More information

WORKERS' COMPENSATION INFORMATION

WORKERS' COMPENSATION INFORMATION Carnegie Mellon University Human Resources Benefits & Compensation Office 5000 Forbes Avenue, 319 SCRG Pittsburgh, PA 15213-3730 (412) 268-2047 Fax: (412) 268-7472 WORKERS' COMPENSATION INFORMATION In

More information

DISCOUNT MEDICAL PLAN INFORMATION BOOKLET

DISCOUNT MEDICAL PLAN INFORMATION BOOKLET DISCOUNT MEDICAL PLAN INFORMATION BOOKLET VISION HEARING CHIROPRACTIC DENTAL PRESCRIPTION DRUGS VITAMINS & NUTRITIONAL SUPPLEMENTS 24-HOUR NURSELINE THIS IS AN OPTIONAL NONINSURANCE PLAN. UAPB-TC UAI0497

More information

CLAIM FORM. List all dates unemployment benefits are being or have been paid: From: To ; From: To

CLAIM FORM. List all dates unemployment benefits are being or have been paid: From: To ; From: To Reply To: Please attach a copy of your policy/certificate and a copy of your retail installment contract. incomplete forms may cause a delay in the processing of your claim. Claims Department P.O. Box

More information

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS

COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS COMBINED INSURANCE COMPANY OF AMERICA INSTRUCTIONS FOR FILING CLAIMS GETTING STARTED Follow the Claimant Instructions below to complete the form. Upon completion of the first page you can: Mail OR fax

More information

MoDOT & Patrol Employees Retirement System MPERS Disability Benefits Claim Packet Instructions

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

More information

[PLEASE MAIL APPLICATIONS TO:] [PO Box 13547, Pensacola, FL 32591-3547]

[PLEASE MAIL APPLICATIONS TO:] [PO Box 13547, Pensacola, FL 32591-3547] Aetna Individual Medicare Supplement Plan Application Aetna Life Insurance Company [151 Farmington Avenue, MS 3128, Hartford, CT 06156] [PLEASE MAIL APPLICATIONS TO:] [PO Box 13547, Pensacola, FL 32591-3547]

More information

Injured at work? WHAT TO DO IF YOU ARE INJURED ON THE JOB:

Injured at work? WHAT TO DO IF YOU ARE INJURED ON THE JOB: Injured at work? WHAT TO DO IF YOU ARE INJURED ON THE JOB: In case of medical emergency seek immediate treatment at the nearest medical facility. tify your supervisor immediately and assist in filing a

More information