If you are injured on the job you should: Workers Compensation Forms

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1 Workers Compensation The EHS office is responsible for the administration of the workers compensation system. Anyone who is injured on the job must report the injury, through their supervisor, to the EHS Office. What To Do If You Are Injured On The Job Workers Compensation Forms Medical Treatment - Panel of Doctors Millersville University - Panel of Doctors Millersville University Workers Compensation Provider Prescription Drugs Basic Workers Compensation Indemnity Benefits Workers Compensation Employee Notification Modified Work Supervisor Responsibilities Supervisors Checklist - Reporting Workers Compensation Claims If you are injured on the job you should: Seek immediate medical treatment Notify your supervisor right away (the same day you are injured) Complete the Employees Report of Injury form With your supervisor, complete the Employers Report of Occupational Injury or Disease form (commonly referred to as the "Supervisors Form") Send the forms to the EHS office in Human Resources, Dilworth Hall, care of Debbie Pizzola. Call Debbie at if you have questions. You can also fax the forms to the office at Forms must be submitted to the EHS office within 24 hours of the injury being reported to the supervisor. Workers Compensation Forms Employees Report of Injury Employers Report of Occupational Injury or Disease ("Supervisors Form") Supervisors Checklist Workers Compensation Employee Notification Panel of Doctors - Wallet Card Panel of Doctors - Bulletin Board Poster

2 Medical Treatment - Panel of Doctors Under Pennsylvania Workers Compensation law, you must see a University designated medical provider from a panel of doctors selected by the University, for your initial medical treatment. You must continue to visit a panel doctor physician, if you need treatment, for 90 days from the date of your first visit. DO NOT go to your family doctor for your initial medical treatment or the medical bill may not be reimbursed. You must first go to a panel doctor for treatment. You must continue to visit one of the panel physicians, if you need treatment, for the first 90 days from the date of your first visit. After the 90-day period, if you still need treatment, you may chose to go to another licensed physician or practitioner of the healing arts of treatment. At any time during the 90 day period, the panel physician may refer you to a specialist or other medical professional. If you are referred to another physician or you continue to need medical care after the 90 day period with a non panel doctor, please inform the EHS office at If you are faced with an immediate medical emergency, you may secure initial assistance from a hospital emergency room of your choice. You should then seek treatment from a licensed physician or practitioner of the healing arts listed on the panel of physicians, for the first 90 days from the date of your first treatment.

3 Millersville University - Panel of Doctors Physician/Practitioner Millersville University Health Services - Witmer Health Center Worknet Occupational Medicine Lancaster General Hospital - Occupational Medicine Lancaster General Hospital - Physical Therapy Eye Physicians of Lancaster Lancaster General Hospital - Emergency Room Lancaster Regional Medical Center - Emergency Room Heart of Lancaster - Emergency Room Address 4 McCollough Street PO Box 1002 Millersville PA Rohrestown Road, 2nd floor Lancaster, PA Harrisburg Pike, Suite Harrisburg Pike Plaza Boulevard, Suite 103 Lancaster, PA North Duke Street Lancaster, PA College Avenue Highlands Drive Lititz, PA You will be issued a wallet card containing the names, addresses, and phone numbers of the panel doctors. Please keep the wallet card with you. In addition, posters are displayed in campus buildings (look for the poster at your buildings bulletin board) with the same information.

4 Millersville University Workers Compensation Provider Your doctor and hospital bills related to your injury are paid by: Inservco Insurance Services, Inc. PO Box North Second Street, Sixth Floor Harrisburg, PA Your medical provider should submit bills to Inservco for payment. Do not forward bills relating to your injury to your health insurance plan. Prescription Drugs You should pay for prescriptions relating to your injury and submit the receipts to Inservco for reimbursement. Do not use your prescription card. If you have questions, call the EHS Office at Basic Workers Compensation Indemnity Benefits Your workers compensation indemnity benefits are calculated based on your average weekly wages at the time of your injury. This usually equals about two thirds of gross salary, subject to minimum and maximum amounts. Disability benefits are non-taxable and payable for the duration of the disability. If your disability lasts 7 days or less, no workers compensation is payable. If your disability lasts 8-13 days workers compensation is payable only for the 8th through the 13th days. If your disability lasts 14 days or more, workers compensation is payable for the entire period of the disability (back to day one). Workers Compensation Employee Notification The Pennsylvania Workers Compensation Act requires Millersville University to provide employees with a written notification of their rights and duties regarding employer payment and reasonable surgical and medical services for work related injuries and illnesses. The law requires that the employees acknowledgment that they have received such notification be evidenced in writing. If you are injured on the job you will receive written notification of your rights and duties. You must read, then sign and date the form and return the form to the EHS office. There are two copies of the form, keep one copy for your records.

5 Modified Work Millersville University will work with you, your supervisor, and the treating physician, to find modified work for you in your department. Modified work will only be assigned where available and once you have been authorized to return to work (on a restricted or modified basis) by your physician. The work will be designed to allow you to work, following the doctor prescribed conditions and limitations, without re-injuring yourself. Supervisor Responsibilities Supervisors play an important role in administering the workers compensation system at Millersville University. It is important for supervisors to: Fill out the supervisors injury report form, with the employee, as quickly as possible. Ideally, the supervisor and the employee should meet to discuss what happened and fill out the form, within hours of the injury occurrence. If necessary, the supervisor may have to call the injured employee at home to obtain the information. Send the completed injury forms to the EHS office as soon as possible, within 24 hours of becoming aware of the injury. If, through the post accident investigation process, a significant safety hazard or condition is identified, the supervisor should contact the EHS office immediately so that further investigation and/or corrective actions can be taken. Work closely with the EHS office to implement any corrective actions to prevent future injuries. Work closely with the EHS office to identify any unusual or mitigating circumstances relating to the work related injury. Work closely with the EHS office to identify possible modified work assignments in your department, for those injured employees who have been cleared to return to work, by their physicians, on a modified basis. Supervisors Checklist - Reporting Workers Compensation Claims To help you follow the workers compensation process, use the Supervisors Checklist. The checklist helps you follow the steps necessary for reporting injuries and submitting leave.