THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM

Transcription

1 THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM COBB COUNTY SCHOOL DISTRICT EMPLOYEE REPORT OF WORK RELATED ACCIDENT (770) FOR WORKERS COMPENSATION (678) Office Fax Employee SS# DOB Age Sex Home Address City State Zip Tel# School/Dept Employee Occupation Accident Date Time Date Reported Accident Location Body Part(s) Injured Describe the Accident Witnesses Tel# *ATTENTION: IF MEDICAL TREATMENT IS SOUGHT IT MUST BE WITH AN APPROVED PANEL PHYSICIAN* Medical Treatment? Yes No Name of Treating Doctor/Clinic: Taken via Ambulance? Yes No Left Work Due to Injury? Yes No First Day Out of Work Primary Care Physician Name Tel# Prior Medical Treatment? Have you had prior injury or condition to injured body part(s) Yes No If yes, explain How Can Future Accidents Be Prevented? (Mark all that apply) Employee Training Proper Use of Equipment Improve Task Procedures Improve Work Area Equipment Correction Removal of Hazard Use of Personal Protective Equipment Provide Hazard Warning Enforce Policy/Rule Other Explain: Employee suggestion(s) for preventing similar accidents: Supervisor suggestion(s) for preventing similar incidents: Employee s Signature Date Supervisor s Signature Tel# Date NOTE: CONTACT RISK MANAGEMENT IMMEDIATELY IF MEDICAL TREATMENT IS REQUIRED. PLEASE SUBMIT SIGNED SUPERVISOR S REPORT AND THE SIGNED MEDICAL RELEASE WITHIN 48 HOURS. Please maintain a copy of this form for your records. Thank you. Revised 7/2015

2 Cobb County School District Risk Management Department Office (770) Fax (678) MEDICAL RELEASE AUTHORIZATION FORM Please submit signed medical release form, as well as the Supervisor s Report of Injury, to the Risk Management Department within 48 hours of injury. Keep a copy for your site files. Release of Medical Information: I authorize the release to my employer and Workers Compensation Company all records relevant to my disability and my claim for disability or Workers Compensation benefits, including, but not limited to, medical diagnosis, prognosis, treatment and periods of hospitalization. It is understood that the Risk Management Department will use the information to verify my disability and determine my eligibility of appropriate benefits. This authorization applies to physicians and other health care providers, hospitals, clinics, insurance companies, Workers Compensation carriers and organizations administering benefit programs. This authorization will remain in effect throughout my claim for Workers Compensation benefits. A photocopy of this authorization will be as valid as the original. Panel of Physicians: I have received a copy of the Bill of Rights for the Injured Worker, as well as, the Traditional Panel of Physicians. Employee s Signature Date Please Print Name 7/2015

3 (This notice must be posted in a conspicuous place readily accessible to the employee at all times.) OFFICIAL NOTICE This business operates under the Georgia Workers Compensation Law. WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR OR FOREMAN. If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker s lost wages. Work Injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A ). The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an employee s claim. A worker injured on the job must select a doctor from the list below. The minimum panel shall consist of at least six physicians, including an orthopedic surgeon with no more than two physicians from industrial clinics (see O.C.G.A ). Further, this panel shall include one minority physician, whenever feasible (see Rule 201 for definition of minority physician). The Board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians are not reasonably accessible. One change of doctor, from the list, may be made without permission. Further changes require the permission of the employer or the State Board of Workers Compensation. State Board of Workers Compensation 270 Peachtree Street, N.W. Atlanta, Georgia or OCCUPATIONAL CLINICS_ WELLSTAR U.S. HEALTH WORKS 3805 Cherokee St., Kennesaw (770) Franklin Rd. SE, Ste. 103, Marietta 3600 Sandy Plains Rd., Marietta (770) (770) Delk Rd., Marietta (770) N. Cooper Lake Rd., Smyrna (770) Fulton Industrial Blvd. SW, Atlanta 4550 Cobb Pkwy, Acworth (770) (404) _ORTHOPAEDICS_ FREDERICK WENER, M.D. CHRISTOPHER EDWARDS, M.D. (Orthopaedic Surgery & Sports Medicine) (Orthopaedic Spine Surgeon) 3969 S. Cobb Drive Ste White Circle Smyrna, GA Marietta, GA (770) Appointment Line: (404) THE CENTER FOR ORTHOPAEDICS & SPORTS MEDICINE RICK HAMMESFAHR, M.D (Leg, Knee, Ankle, Foot) & CRAIG WEIL, M.D. (Shoulder, Arm, Hand, Wrist) 1211 Johnson Ferry Road Marietta, GA (770) PODIATRIST NATHAN SCHWARTZ, DPM ANKLE & FOOT CENTERS OF GEORGIA 861 Windy Hill Road Smyrna, GA (404) The employer/insured providing coverage for this business under the Workers Compensation Law is: COBB COUNTY SCHOOL DISTRICT P.O. BOX 1088, MARIETTA, GA (770) IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS COMPENSATION AT OR OR VISIT Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10, per violation (O.C.G.A and ) WC-P1 (07/2015)

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5 Carlisle Medical/RESTAT Making a Difference Workers Compensation Prescription Information M-F 10am-6pm CST Please present this information to any participating pharmacy for prescription processing Employee Name: (Please Print) Social Security Number (used as Member ID) : - - Date of Birth: Date of Injury: Plan/Group Number: W 908 Member Number: Employee s SS # - - (plus the injury date, NO dashes MM/DD/YY) RESTAT Bin Number: Person Code: 000 Our employee has been injured in a work related accident. Please use the information above to process prescriptions for Cobb County School District. If you have questions, please call our office. Thank You. Melanie Mabry, Medical Claims Adjuster Office ~ Fax ~

6 COBB COUNTY SCHOOL DISTRICT Worker s Compensation ~ Risk Management Mileage Reimbursement Form Fax # EMPLOYEE NAME: DATE STARTING ADDRESS (use complete address with city/zip) DESTINATION~ ADDRESS (Ie: PT, Dr Appt,etc.-use complete address with city/zip ) MILES Roundtrip One Year Deadline With Regard to Medical Expenses Section 4 of SB 233 also creates O.C.G.A (c)(4), which provides for a one year deadline with regard to medical expenses. It states that, Notwithstanding any other provisions of this subsection, if the employee or the provider of healthcare goods or services fails to submit its charges to the employer or its workers compensation insurer within one year of the date of service of the issuance of such goods or services, then the provider is deemed to have waived its right to collect such charges from the employer, its workers compensation insurer, and the employee.