The following state forms have been included in your claims kit packet:

Transcription

1 RE: Workers Compensation Claims Kit Dear Policyholder: Welcome to Tower Group Companies Workers Compensation Insurance Program. Although we hope that your company never experiences an injury to an employee, we want you to have all the information you might need in the event one occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the Iowa statemandated forms, and a step-by-step process to follow in case an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Chicago, Illinois. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Iowa workers compensation process. The following state forms have been included in your claims kit packet: 1. Iowa Form- Employer s First Report of Injury-(FROI)- If the employee claims at least three (3) days of lost time, then the employer must file a report of injury with the commission within four ( 4) days (not including Sundays and legal holidays) after receiving notice or knowledge of the occurrence. The failure to timely file this report can lead to a $1,000 fine per occurrence. 2. Wage Statement- Please complete and send a copy of employees Wage Statement to Tower Group Companies at the time of injury. 3. Iowa Authorization To Release Information Regarding Claimants Seeking Workers Compensation Benefits- Form (11/04)- This form must be signed by the employee and provided to health care providers, former and current employers, etc., to authorize them to release information, including but not limited to, the employee s medical records. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL TGC (08/10)

2 HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Workers compensation claims can be reported in several different ways, you can: Complete and submit the Iowa Form- Employer s First Report of Injury-(FROI)- and submit the form via one of the following: the completed form to wcreportaloss@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

3 CLAIM ADMIN Iowa Workers Compensation FIRST REPORT OF INJURY OR ILLNESS Jurisdiction Code Jurisdiction Claim Number Claim Administrator Name: Claim Representative Business Insurer Name (if different than claim administrator): Phone Number: Mailing Address, City, State, & Postal Code: Claim Administrator Claim Number: Claim Administrator FEIN: Insurer FEIN: Claim Type Code: Employer Name: Employer FEIN: Insured Report Number: Employer Type Code: EMPLOYER Physical Address, City, State, & Postal Code: Mailing Address, City, State, & Postal Code: Industry Code: Insured Location Number: Employer (E) Lessor (L) Employer UI Number: Nature of Business: Employer Contact Name and Business Phone Number: POLICY Insured Name (parent company if different than employer): Insured FEIN: Insured Postal Code: Policy/Contract Number: Coverage Effective Date: Coverage Expiration Date: Self Insurance License/ Certificate Number: Employee Name (First, Middle, Last, & Suffix): Date of Birth: Gender: Tax Filing Status (check one): Mailing Address, City, State, & Postal Code: Date of Hire: Male (M) Single (A) Married/Filing Joint (C) Female (F) Single/Head of Household (B) Married/Filing Separate(D) EMPLOYEE WAGE Phone Number (include area code): Occupation Description: Manual Classification Code: Department Where Regularly Worked: Average Wage $ (check one): hourly daily semi-monthly monthly bi-weekly annual weekly Educational Level (grade completed): [GED = 12] Employment Status (check one): Employee ID Number (check one): Piece Worker Volunteer Seasonal Apprenticeship/Full-Time Apprenticeship/Part-Time Regular Employee/Full-Time Part-Time Other ID # Social Security Number Employment VISA Number Passport Number Green Card Marital Status: (check one) Unmarried (U) Married (M) Separated (S) Employee s Authorization to Release the Following: Medical Records yes Employee ID Assigned by Jurisdiction Social Security Number yes Salary Continued In Lieu of Compensation: yes no Employee Number of Dependents: Full Wages Paid for Date of Injury: yes no Number of Days Regularly Worked Per Week: Discontinued Fringe Benefits: $ Date of Injury Date Employer Had Knowledge of the Injury Date Claim Administrator Had Knowledge of the Injury Initial Date Last Day Worked Initial Return to Work Date (if applicable) Employee Date of Death (if applicable) Describe the nature of the injury. (ex. amputation, burn, cut, fracture): Part(s) of body directly affected by the injury or illness. (ex. hand, arm, circulatory system): no no Employee Number of Exemptions: (check one) Entitled Withholding ACCIDENT/INJURY Time of Injury Time Employee Began Work Pre-Existing Disability Code: Yes No Unknown Accident Premises Code: Employer (E) Lessee (L) Other (X) Accident Site Organization Name: Describe the events that caused the injury. (ex. fell, operating machinery, chemical exposure): Name the object or substance that directly injured the employee. (ex. knife, floor, acid, oil): Accident Site Street, City, State, & Postal Code: Specify activity the employee was engaged in when the event occurred. (ex. cutting metal plate for flooring) Indicate if activity was part of normal duties: Accident Location Narrative (if no street address): Accident Site County/Parish: Witness Name & Business Phone Number: MEDICAL Initial Treatment Code (check one): Initial Medical Provider Name: Managed Care Organization Name or ID Number: no medical treatment (0) minor/on-site treatment (1) clinic/hospital visit (2) Initial Medical Provider Physical Address, City, State, & Postal Code: emergency care (3) ICD Primary Diagnostic Code (if known): hospitalization > 24 hours (4) future medical treatment/lost time anticipated (5) Preparer s Name & Title: Preparer's Company Name: Phone Number: Date: IAIABC FORM 1.2 (12/98)

4 This section is to provide information valuable in handling this claim. The Iowa Occupational Safety and Health Act The following is a summary of the recordkeeping, reporting and posting responsibilities of employers under Iowa s Occupational Safety and Health Act. RECORDKEEPING REQUIREMENTS Regulations issued under the Iowa Occupational Safety and Health Act of 1972 require establishments subject to the Act to maintain records of recordable occupational injuries and illness. Such records must consist of: (a) a log and summary of occupational injuries and illnesses and (b) a supplementary record of each occupational injury and illness. LOG AND SUMMARY OF OCCUPATIONAL INJURIES AND ILLNESSES. Each recordable occupational injury and occupational illness must be entered on a log and summary of cases (0SHA Form No. 200) as early as practicable but no later than six working days after receiving information that a recordable case has occurred. A multi-unit employer may maintain the log and summary of occupational injuries and illnesses at a place other than the establishment if there is a copy of the log and summary available in the establishment complete and current to a date within 45 calendar days. If an equivalent of OSHA Form No 200 is used, such as a printout from data-processing equipment, the information shall be as readable and comprehensible to a person not familiar with the dataprocessing equipment as the OSHA Form No. 200 itself. Logs must be kept current and retained for 5 years following the end of the calendar year to which they relate. SUPPLEMENTARY RECORD OF OCCUPATIONAL INJURIES AND ILLNESSES. To supplement the Log and Summary of Occupational Injuries and Illnesses, each employer must have available a record for each occupational injury or illness at each establishment within six working days after receiving information that a recordable case has occurred, OSHA Form No. 101 may be used for this purpose. State of Iowa Form No [(IAIABC Form 1.2 (12/98)], workers' compensation or other reports are acceptable as records if they contain the information required on OSHA Form No 101. These records must be available in the establishment without delay and at reasonable times for examination by representatives of the Iowa Division of Labor Services, the U.S. Department of Labor and the U.S. Department of Health, Education and Welfare. The records must be maintained for a period of not less than 5 years following the end of the calendar year to which they relate. ANNUAL SUMMARY. Each employer subject to the recordkeeping requirements must prepare a summary of the occupational injury and illness experience of the employees in each of the employer s establishments at the end of each year based on the information contained in the log and summary of occupational injuries and illnesses for the particular establishment. OSHA Form No. 200 shall be used for this purpose. The summary shall be signed and posted in a place accessible to the employees no later than February 1 and shall remain in place until March 1. For employees who do not report to work at a single establishment, or who do not report to any fixed establishment on a regular basis, employers shall satisfy the posting requirement by presenting or mailing a copy of the annual summary during the month of February to all such employees who receive pay during that month. Summaries must be retained for 5 years following the end of the calendar year to which they relate. EMPLOYEES NOT IN FIXED ESTABLISHMENTS. Employers of employees engaged in physically dispersed operations such as occur in construction, installation, repair or service activities who do not report to any fixed establishment on a regular basis but are subject to common supervision may satisfy the recordkeeping provisions with respect to such employees by: (a) Maintaining the required records for each operation or group of operations which is subject to common supervision (field superintendent, field supervision, etc.) in an established central place; (b) Having the address and telephone number of the central place available at each worksite; and (c) Having personnel available at the central place during normal business hours to provide information from the records maintained there by telephone and by mail. (Note: This regulation does not automatically apply to all construction, installation, repair or service activities. If in doubt about applicability to your operations, contact the Iowa Division of Labor Services.) Records for personnel who do not primarily report or work at a single establishment, and who are generally not supervised in their daily work, such as traveling salespersons, technicians, engineers, etc., shall be maintained at the location from which they are paid or the base from which personnel operate to carry out their activities. REPORTING REQUIREMENTS Regulations issued under the Iowa Occupational Safety and Health Act require all employers subject to the Act to report to the Iowa Workers' Compensation Commissioner any occupational injury or illness which temporarily disables an employee for more than three days or which results in permanent total disability, permanent partial disability, or death. The report must be filed electronically in conformity with EDI requirements with the Iowa Division of Workers' Compensation within four days from such event when the injury or illness is alleged by the employee to have been sustained in the course of the employee s employment. A report to the Iowa Division of Workers' Compensation is considered to be a report to the Iowa Division of Labor Services. The Iowa Division of Workers' Compensation shall forward all such reports to the Iowa Division of Labor Services. In addition, employers must report to the Iowa Labor Commissioner within 8 hours each accident or health hazard that results in one or more fatalities or hospitalization of three or more employees. Those establishments selected to participate in the annual Occupational Injuries and Illnesses Survey will be required to prepare a report (OSHA Form No 200-S) based on entries contained on the Log and Summary of Occupational Injuries and Illnesses. POSTING REQUIREMENTS The Iowa Occupational Safety and Health Act requires that employees be informed of the job safety and health protection provided under the Act. The poster, Safety and Health Protection on the Job, is to be used for this purpose, and must be posted in a prominent place in the establishment to which the employees usually report to work. The poster briefly states the intent and coverage of the Act and the responsibilities of employers and employees to maintain safe and healthful working conditions. EMPLOYERS WHO MUST KEEP OSHA RECORDS Employers with 11 or more employees (at any one time in the previous calendar year) in the following industries must keep OSHA records. The industries are identified by name and by the appropriate Standard Industrial Classification (SIC) code: Agriculture, forestry, and fishing (SIC s and 07-09) Oil and gas extraction (SIC 13 and 1477) Construction (SIC s 15-17) Manufacturing (SIC s 20-39) Transportation and public utilities (SIC s and 44-49) Wholesale trade (SIC s 50-51) Building materials and garden supplies (SIC 52) General merchandise and food stores (SIC s 53 and 54) Hotels and other lodging places (SIC 70) Repair services (SIC s 75 and 76) Amusement and recreation services (SIC 79) Health services (SIC 80), and State and local government (Above SIC s plus 91-97). If employers in any of the industries listed above have more than one establishment with combined employment of 11 or more employees, records must be kept for each individual establishment. All employers, including small employers and those in exempted SIC s, must continue to meet the requirement to report fatalities or multiple (3 or more) hospitalizations and all occupational injuries or occupational illnesses that result in a workers' compensation case. If an employer is notified in writing by the Bureau of Labor Statistics about having been selected to participate in a statistical survey, such employer, including small employers, and those in exempted SIC s, must maintain a log and summary of all occupational injuries and illnesses for that year. The notification will contain the necessary form and instructions to comply with the survey requirements. The Iowa Workers Compensation Act The following is a summary of the recordkeeping and reporting responsibilities of employers under the Iowa Workers Compensation Act. RECORDS AND REPORTS Every employer shall keep a record of all injuries sustained by employees in the course of their employment resulting in incapacity for longer than one day. An employer with notice or knowledge of an injury which temporarily disables an employee for more than three (3) days or results in permanent total disability, permanent partial disability or death is required to electronically file a report with the Workers' Compensation Commissioner within four (4) days from such event when such injury is alleged by the employee to have been sustained in the course of employment. All books, records, and payrolls of an employer are required to be open for inspection by the Workers' Compensation Commissioner for purposes of administration of the Iowa Workers Compensation Act. The Workers' Compensation Commissioner may require an employer to appear and show cause why the employer should not be subject to a civil penalty of $1, per occurrence for failure to comply with the reporting or inspection requirements. Upon hearing, if the facts indicate, the commissioner may enter an order requiring payment of such penalty. Unless voluntarily paid, the commissioner may petition the district court for entry of judgment on the order. The employer s insurance carrier shall be responsible in the same manner and to the same extent as the employer when a report of injury has been submitted to the employer s insurance carrier and not filed by them with the Workers' Compensation Commissioner. The employer is required to furnish to an employee, on request, one statement of earnings, wages, or salary for the year preceding the injury. An employer may be subject to a civil penalty of $ per offense for refusal to furnish such wage statement. INSTRUCTIONS An employer with notice or knowledge of an injury which temporarily disables an employee for more than THREE (3) days or results in permanent total disability, permanent partial disability or death is required to electronically file a first report of injury with the Iowa DIVISION OF WORKERS' COMPENSATION within FOUR (4) days from such event when such injury is alleged by the employee to have been sustained in the course of the employee s employment. A report to the Iowa DIVISION OF WORKERS' COMPENSATION is considered to also be a report to the Iowa DIVISION OF LABOR SERVICES. The Iowa DIVISION OF WORKERS' COMPENSATION forwards the report to the Iowa Division of Labor Services. Employers should report ALL injuries to their insurance carrier or third party administrator. ALL REPORTS MUST BE FILLED IN COMPLETELY AND SIGNED. PLEASE TYPE OR PRINT LEGIBLY. This form contains all items requested on OSHA form No 101, Supplementary Record of Occupational Injuries and Illness. THE INFORMATION PROVIDED WILL BE OPEN FOR PUBLIC INSPECTION UNDER Iowa Code Iowa Form (11/04)

5 W AGE S TATEMENT Employer: Employee: Please provide the 52 weeks of wages prior to the date of injury of Date employee ceased to work: Number of Hours employee is scheduled to work per week: Is employee paid by hour, day, week or month Date Hired Claim Number At what rate: Does Employee work Overtime Yes No If yes, is Overtime mandatory Yes No State the date and amount of any pay increases during the past 52 weeks Date Amount Date Amount Date Amount Date Amount Dates Incl of each Week Pd Hrs Wkd Regular Pay Overtime Pay Dates Incl of each Week Pd From To Yr From To Yr Hrs Wkd Regular Pay Overtime Pay SUBTOTAL SUBTOTAL GRAND TOTAL This is a correct statement of Employee s earnings as actually taken from Payroll Records Employer s Signature Title Date

6 AUTHORIZATION TO RELEASE INFORMATION REGARDING CLAIMANTS SEEKING WORKERS' COMPENSATION BENEFITS Name of Patient: Date of Birth: SECTION I. AUTHORIZATION FOR RELEASE OF INFORMATION AND FOR REDISCLOSURE I authorize to disclose and deliver to: the following information related to me: Any and all information EXCEPT substance abuse (drug or alcohol), mental health, and AIDS-related information, unless specifically authorized to be released in section II of this form. NOTE: If the information includes mental health treatment, substance abuse treatment or HIV-related information it will not be released unless the undersigned patient agrees to the release on the reverse side of this form. I understand the information is being disclosed and may be used only for legal and/or litigation purposes relating to claims and/or suit against I understand that this Authorization may be used to obtain information from health care providers, schools, former and current employers, providers of vocational rehabilitation services, the Social Security Administration, and the Iowa Department of Workforce Development. I understand that I have a right to inspect the disclosed information at any time. This authorization is effective until the conclusion of a contested case on the claim. I understand that I may revoke this Authorization, except to the extent that action has already been taken in reliance upon it, by giving written notice to the health care provider or record keeper. I also understand that if I revoke, the revocation will take effect on the day it is received in writing by the entity from whom disclosure is sought. I understand that if the person or entity that receives the information requested is not covered by the federal privacy regulations or is not an individual or entity who has signed an agreement with such a person or entity, the information described above may be redisclosed and will no longer be protected by the regulations. Iowa and Federal law provide that I have a right to prohibit redisclosure of confidential medical information and further disclosure may not be had without my express written authorization, except as indicated below. I understand that the Recipient of this Authorization, WITHOUT FURTHER AUTHORIZATION, may redisclose this information to: Parties and their legal counsel, insurers, experts, potential experts, but only after they have been advised of their obligations under the law and this authorization, including the prohibition against redisclosure of this information; Agents, employees or representatives of the parties, but only after they are involved in conducting the prosecution or defense of the case, and only after they have been advised of their obligations under the law and this authorization, including the prohibition against redisclosure of this information; Administrative agency and court officials hearing the claim, and their support staff. I SPECIFICALLY AUTHORIZE AND CONSENT TO ANY SAID DISCLOSURE AND REDISCLOSURE DESCRIBED ABOVE. Claimant or Legal Representative Date Printed Name and Relationship of Claimant's Legal Representative

7 SECTION II. SPECIFIC AUTHORIZATION FOR RELEASE OF INFORMATION PROTECTED BY STATE OR FEDERAL LAW CONCERNING MENTAL HEALTH, SUBSTANCE ABUSE TREATMENT OR AIDS-RELATED INFORMATION I acknowledge that information to be released may include material that is protected by Federal and/or State law applicable to substance abuse, mental health, and/or AIDS-related information. I SPECIFICALLY AUTHORIZE the release of confidential information relating to: [Place "YES" or "NO" in ALL applicable boxes:] Substance Abuse (Drug or Alcohol) information from all health care providers and facilities and any other person or entity in possession of records concerning me. Mental Health information from all health care providers and facilities and any other person or entity in possession of records concerning me. HIV or AIDS-related information, Diagnosis, and test results from all health care providers and facilities and any other person or entity in possession of records concerning me. Furthermore, I SPECIFICALLY AUTHORIZE disclosure and re-disclosure of this confidential information to all of the persons referred to in the REDISCLOSURE Section I. In order for the above information to be released you must sign here AND at the end of Section I Signature of Claimant or Legal Representative Date Street Address City/State/ Zip Code Printed Name and Relationship of Claimant's Legal Representative Federal and/or State law specifically require that any disclosure or REDISCLOSURE of substance abuse, alcohol or drug, mental health, or AIDS-related information must be accompanied by the following written statement: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. See also Chapter 228 of the Iowa Code and Section (3) of the Iowa Code and other applicable laws (11-04) This form my be used in connection with claims under the jurisdiction of the Iowa Workers Compensation Commissioner.

8 WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Inc. strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Inc. participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medial Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at x4680. Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via Internet Access: For the standard national workers compensation network go to and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network. If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop down box.

9 a. For the Texas HCN Specialty Network go to and click on any of the search buttons. In order to select the proper Texas HCN network, please select the Coventry HCN from the Networks drop down box. b. For the California MPN Specialty Network go to and click on any of the search buttons. In order to select the proper CA MPN network, please select the First Health Select CA MPN from the Networks drop down box. c. For large panel card production or if you require additional information regarding web access please contact Tower Group Inc. Medical Management division at Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group Inc. designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your adjuster, or Tower Group Inc Managed Care Services, if you have any questions regarding these programs.

10 Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al

11 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: 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. Questions? Call Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY 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 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 NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information from the card. 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 your local Walgreens or Rite Aid Pharmacy Call us: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

12 First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al Need help in English? Call Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN 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 Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) 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. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

13 Administered By: