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

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1 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 emergency, advise the injured employee that she/he has the right to seek medical treatment. 2. Call the Broome County Office of Risk & Insurance Management ( ) within 12 hours with the following information: a. The name of the injured worker b. The Department / Town / Village where the employee works c. A brief description of the injury and how it occurred. d. Where the employee went for medical treatment. 3. The Supervisor must also be aware of any policies within their own department or Town/Village regarding the reporting/documenting of Workers Compensation injuries. 4. Call your department/division head if the employee goes for immediate medical attention or if the employee is taken out of work. 5. Tear off this top instruction page and give remaining forms to the employee to complete 6. Review and sign the accident report completed by the employee and forward the completed forms to your department s payroll contact within 24 hours of the injury. 7. If the employee does not return the forms to you within 24 hours of the injury, contact the employee and require him/her to send you the completed forms. There are strict time limits for Broome County to report all injuries to the Workers' Compensation Board. 8. The Office of Risk & Insurance needs to be contacted if there is any change in the employee s working status due to this injury and remind the employee that an updated physician s report is required for all changes in work status. ( ) Department s (Payroll contact) Responsibilities: Complete WC Form 4 (administrative report) and forward the completed original packet to the Office of Risk & Insurance. Send all future physician reports and return to work notifications to Risk & Insurance. Supervisor Instructions

2 Employee instructions for Reporting Workers' Compensation Injury Updated January 1, 2012 Keep these instructions for future reference 1. Complete WC Form 1 (accident report), WC Form 2 (Authorization) WC Form 3 (Notice to Employees) and WC Form 5 (If treatment is obtained). 2. Give the packet, except WC Form 5 to your supervisor. 3. Give WC Form 5 (physician s report) to your doctor at each visit. After the doctor visit return the completed WC Form 5 to Risk & Insurance or your department if you are capable of returning to modified duty. 4. All requests for Diagnostic Testing must be scheduled through our Network. Failure to schedule through the appropriate network, will result in refusal of payment. All requests for treatment should be faxed to Colleen at (607) Billing information: You are responsible for notifying your physician of the proper billing information. Be sure to mark the date of injury clearly on all correspondence and make sure all bills are sent to: Broome County Office of Risk & Insurance Management P.O. Box 1766 Binghamton, NY Do not pay for Prescriptions! Provide your pharmacy with the above noted address for billing purposes. If you pay full price for a prescription, you will only be reimbursed the allowable amount under the New York State Workers Compensation Fee Schedule. 7. Note if you advise your health insurance carrier that you were hurt it will protect you. 8. If you have any questions regarding your claim, please call Please take this form with you to your appointment for billing purposes. Instructions

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4 WORKERS' COMPENSATION ACCIDENT REPORT Answer all questions fully. Attach additional sheets as needed. Employee Name: SSN: Date of Injury: Time of Injury: Hour began work: Employer (i.e. BC highway, Town/Village, etc): Where did the accident happen? (i.e. hallway, Main St, front door etc): Is this your normal work location? Yes No If no, why were you there? What job duty were you performing when you were hurt? Describe in detail how you were injured (i.e.,tripped and fell, etc): Body Part Injured (Specify Left or Right): Type of Injury (i.e. bruise, cut, break, etc): Please list witness s to the accident: Was the injury the result of the use/operation of a licensed motor vehicle? Yes No If Yes, Employee s vehicle Employer s vehicle Other vehicle Where did you receive your first medical treatment for this injury On Site Doctor s Ofc Emergency Room Clinic/Hospital/Urgent Care Hospital Stay over 24 hours Who treated you and where? Are you still being treated for this injury/illness? Yes No If yes, name and address of treating doctor(s): Have you ever had injuries or health problems, work related or not, involving this body part(s)? Yes No If yes, please provide Doctor(s) Name: It is a crime punishable as a Class A Misdemeanor under the laws of the State of New York for a person in and by a written instrument to knowingly make a false statement or to make a statement which such person does not believe to be true. Employee Signature To be completed by Supervisor Did a Supervisor witness the injury? Yes No If No, date notified of injury: I agree I disagree with the employee s statement Date Completed Supervisor s Name and phone number (please Print) Supervisor Signature and Date WC Form1

5 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION MUST BE SIGNED FOR PAYMENT OF MEDICAL BILLS I, authorize the use and disclosure of Health Information as Print Name described in this authorization. Specific person/organization or class of persons authorized to provide information: Licensed physician, medical practitioner, nurse, pharmacist, hospital, clinic, other medical or medically-related facility, insurance or reinsurance company, consumer reporting agency, employer or former employer. Specific person/organization authorized to receive and use information: Broome County Office of Risk & Insurance and legal representatives, RMSCO, Inc. and Corporate Care Management, Inc (or current Nurse Case Management Firm) Specific and meaningful description of the information: Any and all office notes, diagnostic test results, x-rays, and hospital records. Purpose of the request: To evaluate the claim for Workers' Compensation Benefits, to determine causal relationship, apportionment, and possible Second Injury Fund relief. Right to Revoke: I understand that I have the right to revoke this authorization at any time by notifying Broome County Office of Risk & Insurance, Inc., P.O. Box 1766, Binghamton, NY in writing. I understand that this revocation is only effective after it is received and logged in by RMSCO, Inc. I understand that this revocation will not apply to any use or disclosure made prior to its activation by RMSCO, Inc. I understand that after this information is disclosed, federal law may not protect it and the recipient may re-disclose it for the purposes stated above. I understand that failure to sign this authorization could result in delayed processing of my claim and the Carrier s inability to pay related medical expenses. I understand that I may receive a copy of this authorization. I understand that this authorization will expire when my claim for Workers' Compensation benefits is concluded unless revoked prior to. Signature of Claimant: Date of Birth: Employer: Date: WC Form 2

6 NOTICE TO EMPLOYEES RECEIVING WORKERS' COMPENSATION BENEFITS If you are receiving weekly workers' compensation, you must report any other earnings you receive to the Broome County Office of Risk & Insurance. "Earnings" includes any cash, wages, or salary received from 1. self-employment 2. any employer other than the employer where you were injured. Earnings also include commissions, bonuses, and the cash value for all payments received in any medium other than cash (e.g. a building custodian receiving an apartment rent free). Failure to report earnings as defined will subject you to criminal prosecution and civil liability, including the suspension or forfeiture of your benefits. Your endorsement on a benefit check, or deposit of the check into an account, is your statement that you are entitled to receive workers' compensation benefits. Your signature on a benefit check is a further affirmation that you have made no false claims or statements or concealed any material fact regarding your workers' compensation claim. I have read and understand the above. Date Employee signature WC Form 3

7 ADMINISTRATION REPORT / WORKERS COMPENSATION To be filled out by Payroll Contact in Department All fields must be completed to comply with New York State Compensation Forms ADDITIONAL INFORMATION Name: Address: (First) (Middle) (Last) (Social Security No) (Street Address) (City) (State) (Zip Code) Phone No.: Date of Birth: Age: Sex: Department employed by (i.e. Highway, Nursing, Corrections, etc.): Job Title: Date of Hire: Employee s Average Weekly Wage: (Must be filled in - required to calculate employee benefits) Full time Part time Usual Work Week Mon Tue Wed Thu Fri Sat Sun Varies Work Status and Payment Information Date of Accident: First date out of work per Doctor s note Is the employee using benefit time to cover lost days? Yes No If yes, when will the employee run out of benefit time? Date of return to work: If returned, Light Duty Full Duty Person to contact: Phone Number: (Name and Title) WC Form 4

8 EMPLOYEE NAME DEPT. AND DIVISION DATE OF INJURY For Physician use only Treating Physician s Workers Compensation Report To the employee: You must give this form to your physician at each visit In your medical opinion is this injury related to the individual s job? Yes No Current degree of disability Mild (25%) Moderate (50%) Marked (75%) Total (100%) Taking into consideration the degree of disability you identified the employee: Can return to work without restrictions / / Cannot return to work until / / Return to work with restrictions indicated below effective / / through / / Broome County has a comprehensive modified duty program & can accommodate most restrictions. The information provided in this form will be utilized to temporarily assign county employees to modified duty. Please explain in detail in the Additional Comments the nature of your patient s limitation in terms of Hours / Weight. / Range of Motion, etc. NO LIMITED UNRESTRICTED PUSHING NO LIMITED UNRESTRICTED PULLING NO LIMITED UNRESTRICTED BENDING NO LIMITED UNRESTRICTED STOOPING NO LIMITED UNRESTRICTED SITTING NO LIMITED UNRESTRICTED STANDING NO LIMITED UNRESTRICTED TWISTING NO LIMITED UNRESTRICTED CLIMBING NO LIMITED UNRESTRICTED KNEELING Additional Comments NO LIMITED UNRESTRICTED LIFTING Lbs. Max. NO LIMITED UNRESTRICTED OVERHEAD LIFTING Lbs. Max. Additional restrictions: Authorization for the following treatment/test is hereby requested: Requests can be faxed to (607) Attn: Colleen Date of this Exam: Date of Next Appointment: Physician Signature, Address and Phone Number: I acknowledge and agree to the restrictions as marked above: WC Form 5 CLAIMANT S SIGNATURE REQUIRED

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