Hello Everyone; ***PENALTIES ARE POSSIBLE FOR NON-COMPLIANCE

Transcription

1 Hello Everyone; As you are aware, the Tennessee's Workers' Compensation Statute has undergone some drastic changes, which applies to all injuries occurring on or after_july 1, Attached is a claims packet to assist you in reporting your workers' compensation claims. Some of these forms will be new to you, while others you'll be familiar with, but they now must be completed more thoroughly and in a timely manner, again, to avoid financial penalties which range from $50.00 to $10, These forms must be completed and sent to me the same day as the injury, they may be either faxed or ed (send the originals with the first school mail carrier run) I must have the C-20 submitted within the time line or we could have financial penalties. First Report of Injury C-20- Within 24 hours, I must have this form completed and sent to Risk Management within 24 hours of injury in the course and scope of his or her employment. -Panel of Physicians C-42G- This must be signed and dated by the employee and returned to the claims adjuster. This form is not new, however the new law does have guidelines that require it be a "valid panel". For instance, if you have a doctor that has retired or no longer accepts workers compensation patients, you need to make updates to your panel immediately to avoid financial penalties. If there is an emergency situation, YES, please senctthe injured worker to the nearest Hospital, but when the emergency is over, please offer the individual the general panel of physician form, immediately. ***PENALTIES ARE POSSIBLE FOR NON-COMPLIANCE -IDPPA Release- Effective , C-31 medical releases will no longer be used. Please have the injured employee sign, date and return a HIPAA release form to the Workers Comp Clerk (Billie Jean Mitchell). -Employee Accident Report- We now must require tha~ the employee complete this and submit it with First Report of Injury to help with claims investigation and determination of appropriate medical treatment. -Supervisor's Accident Investigation Report- The injured employee's supervisor will need to complete this and submit it this with the First Report of Injury to assist with our claims investigation. -Accident Witness Report- You must have any witness complete this and return to Billie Jean Mitchell, Workers Comp Clerk at the Central Office. ' Thank you, Billie Jean Mitchell

2 :~TNRMT ~ SEC SAf'EiY TENNESSEE RISK MANAGEMENT TRUS T ENG INEERING & CLAIMS MANAGEMENT EMPLOYEE ACCIDENT REPORT Employee Name: Job Title: Department: Date of Accident: Shift Start Time: Time of Accident: A.M. or P.M. Supervisor: Location of Accident: Describe the Nature of the Injury: Describe Exactly What Happened: List Any Witnesses: To Whom Did You Report the Accident/Injury? What did you tell your Supervisor? What did your Supervisor Do? Employee Signature Date

3 :;TNRMT ~ SEC SAFETY TC:NNESSEE R I S K MANAGEMENT TRUS T ENGINEER.ING & CLAIMS MANAGEH NT ACCIDENT WITNESS REPORT Employee Name: Employee Address: Work Number: Job Title: Date of Accident: Time of Accident: Alternate Number: Department: Shift Start Time: A.M. or P.M. Location of Accident: Identify the Employee Involved in the Accident: What were you doing when the accident occurred: Describe Exactly What Happened: List Any Other Witnesses: Witness Signature Date

4 ::TNRMT ~ SEC SAFETY TE NN ESSEE R I SK MANAGEMENT TRU ST ENG INEERING. & CLAIMS MANAGEMENT SUPERVISOR ACCIDENT INVESTIGATION REPORT Employee Name: Job Title: Date of Accident: Time of Accident: Department: Shift Start Time: A.M. or P.M. When Did You Learn of the Injury? Did Injured Employee Receive First Aid? Yes No Was Injury Report or First Aid Delayed? Yes No If Yes, Why? Was Employee Referred for Outside Medical Attention: Yes No If so, Where? Location of Accident: Describe the Nature of the Injury: Describe Exactly What Happened: List Any Witnesses: Supervisor Signature Date

5 ::TNRMT TE NN E SS E E RISK MANA GE M E NT r RUS T ~ SEC SAFETY ENG INEERING & CLA IMS MANAGEMENT MEDICAL AUTHORIZATION RE: Name: DOB: SSN: l. In accordance with the provisions of the Privacy Rule for the Health Insurance Portability and Accountability Act, I, do hereby expressly authorize any and all hospitals, physicians, clinics, chiropractors, pharmacists, therapists, and any and all other medical personnel and health care providers, to provide my medical records and/or medical information to my Employer, Insurer, Tennessee Risk Management Trust, its Third Party Administrator, Safety Engineering Consultants, Inc., and/or nurse case manager; said records including, but not limited to, all reports, records, clinical notes, diagnostic tests, operative notes, billing, and all other documentation or information produced by the aforesaid providers and pertaining to my medical care; and said aforesaid providers are hereby authorized and ordered to release said records to my Employer, Insurer, Tennessee Risk Management Trust, its Third Party Administrator, Safety Engineering Consultants, Inc., and/or nurse case manager for inspection and use, and any records obtained pursuant to this Authorization shall not be used or released to any third party not connected with my workers' compensation claim. This authorization specifically authorizes the aforementioned hospitals, physicians, clinics, chiropractors, pharmacists, therapists, and any and all other medical personnel and health care providers, to have communications, either in person, via telephone, or in writing, with my Employer, Insurer, Tennessee Risk Management Trust, its Third Party Administrator, Safety Engineering Consultants, Inc., and/or nurse case manager, regarding any aspect of my medical condition, including but not limited to diagnosis, etiology, medical restrictions, medical impairment, and prognosis. 2. A photocopy of this Medical Authorization shall be deemed as effective and valid as the original. 3. I understand that this Medical Authorization allows the disclosure of reports, records, clinical notes, diagnostic tests, operative notes, and other documentation or information pertaining to psychotherapy treatment. 4. I understand that I have the right to revoke this authorization at any time. I understand that if I do revoke this authorization, I must do so in writing and present my written revocation to My Employer, Insurer, Tennessee Risk Management Trust, its Third Party Administrator, Safety Engineering Consultants, Inc., and/or nurse case manager. Said revocation will be effective only when a covered entity which had previously been authorized to make disclosure receives the written notification of revocation. A revocation will not be effective to the extent that a covered entity has already taken action in reliance thereon. 5. Unless otherwise revoked, this Authorization will be effective during the pendency of my workers' compensation claim. Page 1of2

6 :;TNRMT ~ SEC SAFEi'f TENNESSEE RISK MANAGEMENl rrust ENGINEERING & CLAIMS MANAGEMENT 6. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. 7. I understand that treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this Medical Authorization. 8. My Employer, Insurer, Tennessee Risk Management Trust, its Third Party Administrator, Safety Engineering Consultants, Inc., and/or nurse case manager, are hereby released from any and all liability or responsibility which could or might result because of the disclosure of any information pursuant to this authorization including, but not limited to, liability resulting from any breach of an implied covenant of confidentiality. 9. 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 1 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. Signature of Employee Date Page 1of2

7 FORMC-31 TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation MEDICAL WAIVER AND CONSENT It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment,fines and denial of insurance benefits. THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE DIVISION OF WORKERS' COMPENSATION TO OBTAIN MEDICAL INFORMATION THROUGH ORAL OR WRITTEN COMMUNICATION, INCLUDING, BUT NOT LIMITED TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A MEDICAL PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A AND A MEDICAL PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE EMPLOYEE'S TREATMENT. I,, having filed a claim for workers' compensation benefits, do hereby authorize (Name of Medical Provider) to furnish to the employer (or the employer's representative, such as the insurance company) and/or the Division of Workers' Compensation any information reasonably related to my workrelated injury. The authorization includes, but is not restricted to, a right to review and obtain copies of all records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of treatment. This authorization shall remain valid for I 80 days following its execution. A photocopy of the authorization may be accepted in lieu of the original. Dated: ' 20_ Patient Social Security last four numbers Witness Pursuant to the Rules of the Department of Labor and Workforce Development , any physician, psychiatrist, chiropractor, podiatrist, hospital or health care provider shall, within a reasonable time, not to exceed thirty (30) days, provide the requesting party with any information or written material reasonably related to the injury for which the employee claims compensation. LB-0379 (REV. 07/09) RDA

8 FORMC-42G TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Division of Workers' Compensation Nashville, Tennessee Website: Telephone: EMPLOYEE'S CHOICE OF PHYSICIAN It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits. THIS FORM IS ONLY FOR USE BY GOVERNMENTAL ENTITIES ESTABLISHED BY TCA AND SELF INSURED POOLS ESTABLISHED BY TCA (c)(l). State File Number: _ Date of Injury: _ Employee: SSN: Address: City: State: Zip: Employer: HAWKINS COUNTY BOE FEIN: Address: 200 N. DEPOT STREET City: ROGERSVILLE State: TN Zip: _ PANEL OF PHYSICIANS Tennessee Code Annotated (a)(4)(A) requires an employer to offer a panel of three physicians to the injured employee. The injured employee must select a physician from the panel. Physicians Name: DR. JOSE VELASCO & DR MARK DALLE-A VE Phone: Address: 900 WEST MAIN STREET City: ROGERSVILLE State: TN Zip: _ ls Physician a Specialist? 0 Yes 0 No If yes, give specialty: Ortho, Neuro, etc. Physicians Name: DR. AMY HA YNES Phone: Address: 405 SCENIC DRIVE City: ROGERSVILLE State: TN Zip: _ Is Physician a Specialist? 0 Yes 0 No If yes, give specialty: Ortho, Neuro, etc Physicians Name: DR. AMANDA STOLT Phone: _ Address: 4966 HWY 11 WEST City: ROGERSVILLE State: TN Zip: _ ls Physician a Specialist? 0 Yes D No If yes, give specialty: Ortho, Neuro, etc. Physicians Name: DR. SAMUEL BREEDING & DR. TERRY PUCKETT Phone: Address: 105 W. STONE DR., STE. 1 J City: KINGSPORT State: TN Zip: _ Is Physician a Specialist? D Yes D No If yes, give specialty: Ortho, Neuro, etc Physicians Name: HOLSTON VALLEY MEDICAL CENTER Phone: Address: 130 WEST RA VINE ROAD City: KINGSPORT State: TN Zip: _ Is Physician a Specialist? D Yes D No If yes, give specialty: Ortho, Neuro, etc I hereby have selected the following physician from the list provided to me by my employer: Physician Chosen: Employee Signature: Date Selected: _ A copy of this form must be provided to the employee. The employer must keep the original form on file and upon request provide a copy to the Division of Workers' Compensation. This form is required to be in compliance with Tennessee Code Annotated LB-0382 (rev. 7/04)

9 ;:;TNRMT TENNESSLE RISK MA N AGEMENT TRUS T " SEC - SAFETY ENGINEERING &CLAIMS MANAGEMENT I hereby certify that this claim is true and correct. Name: Mileage Request Form T.C.A (a)(6)(A) provides that "when an injured worker is required by the worker's employer to travel to an authorized medical provider or facility located outside a radius of fifteen (15) miles from such insured worker's residence or workplace then upon request such employee shall be reimbursed for reasonable travel expenses." Effective July 1, 2014 the reimbursement rate is $.47 per mile by the Department of Finance and Administration. DATE START LOCATION (HOME OR WORK) END LOCATION (MEDICAL PROVIDER OR FACILITY NAME) MILES ROUNDTRIP Total Number of Miles: I , Please forward to your Claims Representative