Office of Human Resources (814) 865-0424 The Pennsylvania State University Workers Compensation 410 James M. Elliott Building University Park, PA 16802 Please have the employee complete this Workers Compensation Signature Packet as soon as an injury report is completed using our online first report of injury system. 1. Workers Compensation Employee Notification Form 2. Employee Description of Injury Form 3. Workers Compensation Information Sheet 4. Workability Form (Form to be used when seeking medical treatment) 5. Medical Records Release Authorization 6. TMESYS Pharmacy Program 7. Steps to WC Brochure at Penn State Please return signed documents to: Office of Human Resources Workers Compensation Department 410 James M. Elliott Building University Park, PA 16802 Phone: (814) 865-0424 Fax: (814) 865-6820 Penn State is committed to affirmative action, equal opportunity and the diversity of its workforce.
EMPLOYEE DESCRIPTION OF INJURY FORM Date of injury: Date injury was reported: Time: AM/PM Reported to PSU ID # Name of Injured Person (Please Print): Address: Phone Number(s) Date of Birth: Male Female Type of Injury: Body Part(s) affected Details of injury 1. Please describe in your own words how the injury occurred. Include specific details such as equipment used, tools, etc. (Please Print) 2. Please describe where the injury occurred and what activity you were performing when the injury occurred. (Please Print) (Continue on the back of this form to add additional details.) Witness to the injury: Name Contact Number Signature of Employee Date: MAIL COMPLETED FORM PROMPTLY TO PENN STATE WORKERS COMPENSATION, 410 JAMES M. ELLIOTT BUILDING, UNIVERSITY PARK, PA 16802. For Workers Compensation Use Only: Claim Number An Equal Opportunity University OHR 3/10
WORKERS COMPENSATION INFORMATION To All Employees: The Workers Compensation law provides some replacement wages and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. Employers are required to post the name of the company responsible for paying workers compensation benefits in a prominent and easily accessible place; including areas used for the treatment of injured employees or for the administration of first aid. Penn State s Workers Compensation coverage is provided through the Sedgwick. You should report immediately any injury or work-related illness to your supervisor or human resources representative. Your benefits could be delayed or denied if you do not notify your supervisor or human resources representative immediately. If your claim is denied by Sedgwick, then you have the right to request a hearing before a Workers Compensation Judge. The Bureau of Workers Compensation cannot provide legal advice. However, you may contact the Bureau of Workers Compensation for additional general information at: Bureau of Workers Compensation 1171 South Cameron Street, Room 103 Harrisburg, Pennsylvania 17104-2501 Telephone No. within Pennsylvania: 800-482-2383 Telephone No. outside of this Commonwealth: 717-772-4447 TTY 800-362-4228 (for hearing and speech impaired only) www.state.pa.us, pa keyword: workers comp. In addition you can contact your human resources representative or the University s Workers Compensation Office (814-865-0424) if you have any questions about Penn State s policies. Also attached to this sheet is a complete list of panel physicians and medical providers for your reference. EMPLOYEE SIGNATURE: DATE: EMPLOYEE NAME (PRINTED): EMPLOYER REPRESENTATIVE: DATE:
OCCUPATIONAL MEDICINE The Pennsylvania State University Office of Human Resources 1850 East Park Avenue, Suite 310 State College, PA 16803 Telephone: (814) 863-8492 Fax: (814) 865-5337 WORKABILITY Clinic: Employee Name: Provider Phone No. PSU ID #: Chief Complaint: Date of Service: Diagnosis: Date of Injury: Type of Visit: Initial Follow-Up Date of 1 st Treatment: Work/Visit Instructions: The following written instructions have been discussed and given to the patient. Work Status: Released on. May return to work without restrictions on. Unable to work. May return to work with the following restrictions on. No use of left/right No lifting Limited use of left/right Weight limit lbs. Limited standing/walking Sitting work only Limited bending/twisting No driving Limited squatting/kneeling Limited Rigorous Grasping Other Referrals: Follow-up: PLEASE FAX A COPY OF THIS FORM TO PENN STATE OCCUPATIONAL MEDICINE AT (814) 865-5337. A Penn State University Workability Form has been provided to me. I have read and understand the visit instructions. I have been instructed to contact my Supervisor today and provide him/her with a copy of this form. I authorize Penn State Occupational Medicine to receive complete medical information from the above Provider. Patient Signature: Date: Signature of Health Care Provider Print Name of Health Care Provider Penn State is committed to affirmative action, equal opportunity and the diversity of its workforce.
AUTHORIZATION FOR RELEASE AND USE OF MEDICAL INFORMATION I authorize each of the parties identified below to use and disclose any and all of my individually identifiable medical or health information, as d e s c r i b e d b e l o w, fo r p u r p o s e s o f a d m i n i s t e r i n g m y c l a i m. I u n d e r s t a n d t h a t t h e i n fo r m a t i o n a b o u t m e that I authorize to be used or disclosed may be redisclosed in accordance with the terms of this Authorization by the recipient thereof and may no longer be protected by federal or state privacy laws or regulations. I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means, including written or telephonic communications or by direct interview, whether or not I am present during, or notified of such communications, and I hereby authorize Sedgwick Claims Management Services, Inc., my employer and their representatives and agents ("Sedgwick CMS") to initiate and conduct such communications whether or not I am present or have received notice thereof. 1. What Information is covered by this Authorization? This authorization applies to all medical, health, psychological, and/or psychiatric information, records and reports, including information regarding pre-existing health or medical conditions or illnesses (a) that are in existence while this authorization is valid (see Item 3) and (b) that are related to my workers compensation claim. My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results, x-ray reports, and records received from other health care providers. If directly related to my claimed condition or illness, this information may include the following, Please check yes or no and initial: HIV test results, HIV or AIDS information. YES NO Initial here Psychiatric information. YES NO Initial here Information related to drug or alcohol abuse. YES NO Initial here 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'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. 2. Who may disclose and receive Information under this Authorization? A. I authorize Sedgwick, my Employer, and their representatives and agents to communicate directly both orally and in writing with all treating physicians or medical providers of any kind regarding all facts and opinio ns relevant to my workers compensation claim. I authorize any treating physician or other medical provider to communicate directly both orally and in writing with Sedgwick, my Employer, and their representatives and agents, concerning all aspects of my treatment for the illness or injury for which I am receiving or seeking benefits. B. When relevant to my claim, Sedgwick CMS may re-disclose (without my further authorization) any and all of my individually identifiable medical or health information (whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the following, (a) Any person or facility that attends, treats or examines me; (b) Any person or facility that impacts determination of my claim or that coordinates my benefits; (c) My employer and its affiliates and their representatives, independent contractors and service providers that may receive any such information from my employer to the extent permitted by state or federal law; or (d) The Social Security Administration or a social security or vocational rehabilitation vendor. Sedgwick CMS may use my information obtained pursuant to this authorization in any other claim matter that Sedgwick CMS may administer or handle related to me. 3. How Long this Authorization is Valid? This authorization is valid during the duration of my claim(s) and any future related claims, unless a different period is required under applicable federal or state law. 1
4. Revocation of this Authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at any time by notifying, in writing, Sedgwick CMS of my revocation and that my revocation shall be effective upon Sedgwick CMS' receipt of my notice of revocation. I also understand that my revocation of this Authorization will not have any effect on any actions taken by Sedgwick CMS before it receives my revocation. 5. Processing of Claims. I understand that this Authorization is generally necessary for the processing of my Workers Compensation claim. Failure to sign this Authorization may impair or impede the processing of my claim. 6. Refusal To Sign. I further understand my health care providers will not condition my treatment, payment, enrollment or eligibility on my refusal to sign this Authorization. I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to inspect the disclosed information at any time. A photocopy of this authorization shall be valid and is to be accepted with the same effect as the original. Signature of Patient or Patient's Representative Printed Name of Patient or Patient s Representative Representative s Relationship to Patient, if applicable Date Signed Patient s Address First Day Absent Date of Birth Witness Sedgwick CMS 01/01/2011 Sedgwick Claims Management Services, Inc. NOTICE OF STATE FRAUD REQUIREMENTS Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. 2
First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: Print this page 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. Prescription Card CARRIER/TPA Sedgwick INJURED WORKER NAME SOCIAL SECURITY NUMBER Please provide directly to Pharmacist EMPLOYER/OTHER ENTITY DATE OF INJURY 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 866.599.5426. Attention Pharmacists: Call 800.964.2531 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 800.964.2531 NDC Envoy RxBin 004261 or 002538 RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 800.964.2531. 2. Provide the information listed above. 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 one of the following pharmacy chains: Walgreens Rite Aid Walmart CVS Duane Reade Kroger Publix Safeway Use our pharmacy locator online: www.pmsionline.com/pharmacy-center. Call us: 866.599.5426 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS.
Tmesys Retail Pharmacy Network* More than 60,000 pharmacies, including large chains and many neighborhood independent pharmacies, meaning that your prescription can be filled at most pharmacies nationwide. Accredo Health Group Anchor Pharmacy Arrow Prescription Center Aurora Pharmacy Baker s Pharmacy Bartell Drugs Bashas United Drug Bel Air Pharmacy Big Y Pharmacy Biggs Pharmacy Bi-Lo Bi-Mart Bioscrip Pharmacy BJ s Pharmacy Brookshire s Pharmacy Bruno s Pharmacy Buehler s Pharmacy Caremark Pharmacy Carle Rx Express Carrs Quality Center City Market Pharmacy Clinic Pharmacy Coborn s/cash Wise Concord Drugs Costco Pharmacy Cub Pharmacy CVS Pharmacy D&W Pharmacy Dahl s Pharmacy Dierbergs Dillon Pharmacy Discount Drug Mart Doc s Drug Dominick s Finer Foods Drug Emporium Drug Mart Drug Town Drug Warehouse Drugs For Less E. W. James Pharmacy Eagle Pharmacy Eaton Apothecary Econofoods Pharmacy Edwards Pharmacy Fagen Pharmacy Family Drug Store Family Fare Pharmacy Family Pharmacy Familymeds Pharmacy Farm Fresh Pharmacy Farmer Jack Pharmacy Food 4 Less Pharmacy Food City Pharmacy Food Lion Pharmacy Food Town Pharmacy Food World Pharmacy Fred Meyer Pharmacy Fred s Pharmacy Fruth Pharmacy Fry s Pharmacy Gemmel Pharmacy Gentiva Health Services Genuardi s Pharmacy Gerbes Pharmacy Giant Eagle Pharmacy Giant Pharmacy Glen s Pharmacy Good Day Pharmacy Grand Union Pharmacy Gristedes Pharmacy H-E-B Pharmacy Haggen Foods Hannaford Happy Harry s Harmons Pharmacy Harps Pharmacy Harris Teeter Hartig Drug Harvest Foods Pharmacy Harveys Supermarket Pharmacy Hen House Pharmacy Hi-School Pharmacy Homeland Pharmacy Hometown Pharmacy Hy-Vee Pharmacy Ingles Pharmacy Kmart Pharmacy Kerr Drug King Kullen Pharmacy King Soopers Pharmacy Kings Pharmacy Kinney Drugs Klingensmith s Knight Drugs Kohl s Pharmacy Kohll s Pharmacy Kopp Drug Kroger Pharmacy Lewis Pharmacy Lifechek Drug Longs Drug Louis and Clark Lowes Marketplace Marc s Pharmacy Marsh Drugs Martin s Pharmacy May s Drug Store Med-Fast Pharmacy Medical Arts Pharmacy Medicap Pharmacy Medicine Shoppe Pharmacy (various) Med-X Drug Meijer Pharmacy Minyard Pharmacy Morton Pharmacy Mr. Discount Drugs Navarro Discount Pharmacies NeighborCare Pharmacy No Frills Pharmacy Network Pharmacy Owens Pharmacy P&C Food & Pharmacy Pamida Pharmacy Park Nicollet Pharmacy Pathmark Pharmacy Pavilions Pharmacy PharmaCare Pharmacy Pharmacy Express Pharmacy Plus Pick N Save Pharmacy Piggly Wiggly PrairieStone Pharmacy Price Chopper Pharmacy Price Cutter Pharmacy Publix Pharmacy Q Pharmacy QFC Pharmacy Quality Markets Pharmacy QuickChek Pharmacy QVL Pharmacy Rainbow Pharmacy Raley s Drug Center Ralphs Pharmacy Randalls Pharmacy Reasors Pharmacy Rite Aid Pharmacy Ritzman Natural Health Rosauers Pharmacy RXD Pharmacy Sack n Save Pharmacy Safeway Pharmacy Sam s Pharmacy Save Mart Pharmacy Save-Rite Pharmacy Schnucks Pharmacy Scolaris Pharmacy Sedanos Pharmacy & Discount Shaw s Pharmacy Shaws/Osco Pharmacy Shop n Save Pharmacy Shopko Pharmacy Shoppers Pharmacy ShopRite Pharmacy Snyder Drug Emporium Southern Family Market Star Pharmacy Stop & Shop Pharmacy Sunscript Pharmacy Super 1 Pharmacy Super D Super G Super Foodmart Pharmacy Super Fresh Pharmacy Super Rx Pharmacy Sweetbay The Pharm Thriftway Drugs Thrifty White Drug Times Pharmacy Tom Thumb Pharmacy Tops Pharmacy U-Save Pharmacy Ukrops Pharmacy United Pharmacy USA Drug Vix Pharmacy Vons Pharmacy VG s Pharmacy Waldbaum s Pharmacy Walgreens Wal-Mart Pharmacy Wegman Pharmacy Weis Pharmacy White Drug Winn-Dixie Yokes Pharmacy *List subject to change. This is a partial listing only. 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
6 steps to WORKERS COMPENSATION at Penn State REPORT THE INJURY Penn State wants to help you with every step of your recovery. In order for us to do so, your first step should be to notify your supervisor of any work-related injury. Even if you don t think you need treatment. Your claim will be sent electronically to Penn State s Workers Compensation office. 1 Once reported, an insurance adjuster will review and evaluate your claim to determine whether or not you are eligible for Workers Compensation coverage. Your supervisor will provide you with a copy of the following: Your injury report Employee notification form Healthcare Provider Panel list for your area Retail pharmacy program Workers Compensation information sheet Workability form MEDICAL TREATMENT Penn State Workers Compensation insurance pays related medical and surgical expenses for treatment you receive for injuries sustained on the job. 2 If your injury results in an immediate medical emergency, you should seek urgent care at an emergency facility. If your injury results in the need for ongoing medical care, during the first 90 days of treatment you must use a doctor from Penn State s Healthcare Provider Panel. Failure to treat with a Healthcare Provider Panel during that period may result in unpaid medical expenses. COMMUNICATE 3 Effective communication is essential for all parties involved in the Workers Compensation process. You should remain in contact with your Human Resources Representative, supervisor, and insurance adjuster. You can also call Penn State s Workers Compensation office. PRESCRIPTION COVERAGE 4 Penn State provides a convenient system for you to obtain prescription drug coverage for your work-related injury with no out of pocket expense. The retail pharmacy program is available at many major pharmacies such as CVS, Giant, and Rite Aid. Penn State Office of Human Resources Employee Benefits Workers Compensation 410 James M. Elliott Building University Park, PA 16802 814-865-0424 FAX 814-865-6820 www.ohr.psu.edu/workerscomp RECOVERY Recovery from some injuries may require you to be placed on restricted job duty. A doctor s note placing you on restricted job duty or taking you off of work is required. If your department is unable to accommodate your restrictions or you are medically restricted from performing your job responsibilities, you may be entitled to lost-time wage replacement payments. 5 6 RETURN TO WORK In order to return to work safely, you must provide a doctor s note to your supervisor and Human Resources Representative confirming your release to work. This publication is available in alternative media on request. Penn State is committed to affirmative action, equal opportunity, and the diversity of its workforce. This is a summary of your Workers Compensation benefits. Official policy guidelines supercede this document. BSO06-4057 Limitless Opportunities Office of Human Resources