Wrkers Cmpensatin Emplyee Packet Cmplete the fllwing frms and return t Meagan Vrhies, Claims Crdinatr via fax (817) 735-0127, email at Meagan.Vrhies@untsystem.edu r in persn at Human Resurce Services (EAD-280). Wrkers Cmpensatin Netwrk Acknwledgment Emplyee Ntice f Netwrk Requirements packet is prvided n HRS Webpage Emplyee s Reprt f Injury (SORM-29) Must be filed n later than the third calendar day after the first ntice f injury Authrizatin fr Release f Infrmatin (SORM-16) Must be filed n later than the third calendar day after the first ntice f injury Emplyee s Electin Regarding Utilizatin f Sick & Annual Leave (SORM-80) Must be filed n later than the third calendar day after the first day f lst time Detailed instructins n electin chices attached Witness Statement (SORM-74) This frm shuld be cmpleted by the witness (if applicable)
Wrkers Cmpensatin Netwrk Acknwledgement I have received infrmatin that tells me hw t get health care under wrkers cmpensatin insurance. If I am hurt n the jb and live in the service area described in this infrmatin, I understand that: 1. I must chse a treating dctr frm the list f dctrs in the netwrk. 2. I may ask my HMO primary care physician t agree t serve as my treating dctr. 3. I must g t my treating dctr fr all health care fr my injury. If I need a specialist, my treating dctr will refer me. If I need emergency care, I may g anywhere. 4. The insurance carrier will pay the treating dctr and ther netwrk prviders. 5. I might have t pay the bill if I get health care frm smene ther than a netwrk dctr withut netwrk apprval. (Signature) (Date) (Printed Name) I live at (Street Address) (City) (State) (Zip Cde) Name f Emplyer Name f Netwrk
Dear Emplyee: EMPLOYEE'S REPORT OF INJURY We have received a reprt that yu were injured in the curse f yur emplyment. T prcess yur claim efficiently, please fill in all lines cmpletely and print legibly. Attach additinal sheets if necessary. Name: Last First MI Maiden Address: City: State: Primary Phne Number: Secndary Phne Number: Email address: Scial Security: Gender: M / F Date f Injury: Emplyer: Jb Title: Wrk Schedule: 1) What was the exact lcatin f the accident (street address if pssible): 2) What was happening at the time? (What was ging n arund yu, what were yu ding, what were ther peple ding) 3) Briefly describe what exactly caused the injury: 4) What areas f yur bdy were injured? 5) When and t whm did yu reprt yur injury? Date Time Name: Title Phne Number: 6) List all knwn witnesses. (Cntinue n back if necessary) Name Phne: Name Phne: Name: Phne: 7) Please identify yur Primary Care Physician r family dctr: Name: Phne: 8) Please list the names and phne numbers f all dctrs r treatment prviders yu have seen fr yur injury: Name: Name: Name: Phne: Phne: Phne: 9) Has a dctr taken yu ff wrk? 9 Yes 9 N If s, when was the first day yu missed wrk? 10) If the dctr tk yu ff wrk, have yu returned t wrk? 9 Yes 9 N If nt, when d yu think yu will return t wrk? 11) Date f Last Appintment: 11) Date f Next Appintment: 12) Have yu had previus wrkers cmpensatin injuries? 9 Yes 9 N If Yes, please enter dates f injuries and the bdy parts injured. By affixing my signature, I attest that all infrmatin n this frm is accurate and true. Signature: Date: SORM 29 Rev 7/09
Instructins Emplyee's Reprt f Injury Purpse f Frm: The injured emplyee cmpletes this frm t prvide SORM with infrmatin pertaining t the circumstances surrunding the injury and what has happened since the date f injury. This will help t expedite benefits in a mre timely manner. Filing Deadline: The frm must be received by SORM nt later than the 5th calendar day after the First Reprt f Injury r Illness (DWC 1S) is reprted by the agency. Cmpleted by: This frm shall be cmpleted by the injured emplyee with assistance frm the Claims Crdinatr, if needed. Instructins: 1. The emplyee will address each f the questins cmpletely and is t use additinal pages if necessary. The adjuster needs a cmplete picture f the events surrunding the injury and hw the injury ccurred. Witnesses names and phne numbers, physicians/treatment prviders names and phne numbers and wrk status is needed. The emplyee shuld enter any previus wrkers cmpensatin claims and the bdy parts injured. 2. The injured emplyee will sign and date the frm thereby attesting that all infrmatin n the frm is true and cmplete. Distributin The Claims Crdinatr shall retain the riginal fr the agency file and fax r mail a cpy t: State Office f Risk Management PO Bx 13777 Austin, TX 78711 Fax: (512) 370 9025 Ntice: With few exceptins, an individual is entitled, upn request, t be infrmed abut the infrmatin a state gvernmental bdy cllects abut the individual. Under Sectins 552.021 and 552.023 f the Gvernment Cde the individual is entitled t receive and review the infrmatin and under Sectin 559.004 f the Gvernment Cde the individual is entitled t have the state gvernmental bdy crrect any infrmatin abut the individual that is incrrect. SORM 29 Revised 7/09
AUTHORIZATION FOR RELEASE OF INFORMATION Patient: TO WHOM IT MAY CONCERN: Yu are hereby expressly authrized t release and furnish t the State Office f Risk Management (SORM), and/r any assciate, assistant, representative, agent, r emplyee theref, any and all desired infrmatin (including, but nt limited t, ffice recrds, medical reprts, mems, hspital recrds, labratry reprts, including results f any and all tests including alchl and/r drug tests, X rays, X ray reprts, including cpies theref) pertaining t the physical and/r mental cnditin which is the basis f my wrkers' cmpensatin claim. This includes nt nly all current and/r future infrmatin but als all past medical infrmatin which is related t the injury r injuries which frm the basis f my claim. (Print name) Phtstatic cpies f this signed authrizatin will be cnsidered as valid as the riginal. This is nt a release f claims fr damages. SIGNED: DATED: PLEASE SIGN THE ABOVE MEDICAL AUTHORIZATION AND RETURN IT, SO WE MAY SECURE RELEASE OF YOUR MEDICAL RECORDS. THANK YOU. STATE OFFICE f RISK MANAGEMENT SORM 16 Rev 07/09
Instructins Authrizatin fr Release f Infrmatin Required: This dcument is required immediately after sustaining a wrk related injury. The injured emplyee shuld cmplete this release frm. This enables SORM t btain, frm healthcare prviders, cpies f relevant medical dcuments that will assist in the handling f the claim. Filing Deadline: The frm must be received by SORM nt later than the 5th calendar day after the first ntice f injury is reprted t the agency. Cmpleted by: The emplyee must cmplete this frm. If the emplyee is incapacitated the spuse, child, r legal guardian may sign the frm. THIS FORM MUST BE SIGNED AND DATED. The Claims Crdinatr shuld make this frm available fr all injuries. Instructins: 1. The injured emplyee must clearly print his r her name n the patient line. 2. The injured emplyee must clearly print his r her name n the secnd line. 3. The injured emplyee must sign and date the frm. Distributin: The Claims Crdinatr shall retain the riginal fr the agency file and fax r mail a cpy t: State Office f Risk Management PO Bx 13777 Austin, TX 78711 Fax: (512) 370 9025 Ntice: With few exceptins, an individual is entitled, upn request, t be infrmed abut the infrmatin a state gvernmental bdy cllects abut the individual. Under Sectins 552.021 and 552.023 f the Gvernment Cde the individual is entitled t receive and review the infrmatin and under Sectin 559.004 f the Gvernment Cde the individual is entitled t have the state gvernmental bdy crrect any infrmatin abut the individual that is incrrect. SORM 16 Rev 07/09
EMPLOYEE S ELECTION REGARDING UTILIZATION OF SICK AND ANNUAL LEAVE FOR GENERAL EMPLOYEES Emplyee s Name Date f Injury Yu are nt required t use yur leave. Texas Labr Cde 501.044 allws an injured state emplyee t elect t use accrued sick and annual leave befre receiving incme benefits. Accrued sick leave must be exhausted befre annual leave may be used. Other categries f leave (cmpensatry leave, hliday leave, administrative leave, etc) may nt be used prir t sick and annual leave. Cmplete Electin 1 r Electin 2. ELECTION 1 (must chse A, B, r C) Sick leave must be exhausted befre annual leave may be used When I lse time frm wrk due t this injury r illness, I elect t use all f my accrued sick leave AND: A. All f my accrued annual leave. B. A prtin f my accrued annual leave (enter number f hurs: ). C. Nne f my accrued annual leave. ELECTION 2 When I lse time frm wrk due t this injury r illness, I elect t nt use any accrued sick leave and/r annual leave. I understand I will nt receive wrkers cmpensatin payments until after the seven (7) calendar day waiting perid. I understand that I may nt change my electin after my eighth (8 th ) day f disability and signing this frm. I have read the reverse side f this frm, and I fully understand the electin I am making. Hurs f Sick Leave Emplyee s Scial Security Number Hurs f Annual Leave Agency Emplyee s Signature Date Claims Crdinatr s Signature Date This frm may nt be altered in any way. SORM-80 Rev 07/09v2
Instructins Emplyee s Electin Regarding Utilizatin f Sick and Annual Leave Fr General Emplyees Injured emplyees may elect t use accrued sick leave and all, part, r nne f their accrued annual leave fr time missed frm wrk due t the wrk related injury. Accrued sick leave and accrued annual leave are the amunts f paid leave available at the time f injury in additin t leave earned after the injury. The fllwing details the effects f the different chices available t yu. If Yu Chse Electin 1 Yu must use all accrued sick leave but may elect t use all, sme, r nne f yur accrued annual leave. All sick leave must be exhausted befre annual leave may be used. If yu select 1A and return t wrk but later have additinal days f disability, yu must use any accrued sick and annual leave befre receiving wrkers cmpensatin incme benefits. If yu select 1B, yu must use any sick leave balance and any authrized annual leave befre yu will be eligible t receive wrkers cmpensatin incme benefits. If yu select 1C, yu must use any/all accrued sick leave befre receiving wrkers cmpensatin incme benefits. Wrkers cmpensatin incme benefits d nt begin until the eighth day f disability. Emplyees wh are disabled fr at least 14 days will receive retractive benefits fr any prtin f the seven-day waiting perid nt paid by leave. Yu will cntinue t receive yur full pay as lng as yu have accrued time t use and have authrized yur agency t use it fr yur injury. If yur elected leave is exhausted, yu may receive incme benefits t replace a prtin f yur lst wages. This may be 70% r 75% f yur average weekly wage depending n yur wages at the time f yur injury. It is recmmended that yu cnsult with yur Human Resurces Department t discuss the impact f yur selectin n yur leave balances and insurance benefits shuld yu be ff wrk fr an extended perid f time. If Yu Chse Electin 2 Yu chse t nt use any sick r annual leave fr yur cmpensable injury. Yur agency may immediately place yu in a leave withut pay status. Yu may nt receive any wrkers cmpensatin incme benefits fr the first seven (7) calendar days yu are unable t wrk. If eligible, yur incme replacement benefits will begin n the 8 th day f disability and emplyees wh are unable t wrk fr 14 days will receive retractive benefits fr the first seven days. Yu will be paid at a rate f 70 r 75% f yur weekly wage depending n yur wages at the time f yur injury. Ntice: With few exceptins, an individual is entitled, upn request, t be infrmed abut the infrmatin a state gvernmental bdy cllects abut the individual. Under Sectins 552.021 and 552.023 f the Gvernment Cde the individual is entitled t receive and review the infrmatin and under Sectin 559.004 f the Gvernment Cde the individual is entitled t have the state gvernmental bdy crrect any infrmatin abut the individual that is incrrect. SORM-80 Rev 07/09v2
WITNESS STATEMENT MUST BE TYPED OR PRINTED Witness Name: Residence Address: Primary Telephne: Witness Emplyer: Injured Emplyee SORM Claim Number WC Date f Injury Statement Taken By Witness email address: Secndary Telephne: On this date,, at abut PM / AM I was in r at (clearly state yur wn lcatin) emplyee is reprted t have ccurred. when an accident invlving the abve Check nly ne bx I saw the incident. The accident ccurred in the fllwing manner: Other pertinent infrmatin and surce: I did nt see the incident. Infrmatin given t me by (name f persn) indicates it ccurred as fllws: Other pertinent infrmatin and surce: I knw nthing whatsever abut the ccurrence. Signature Date SORM 74 Rev 07/09
Instructins Witness Statement Required: Immediately after receiving ntice f any injury, the Claims Crdinatr shuld determine the names, addresses, and telephne numbers f all witnesses t the incident. A statement shuld be taken frm each witness and frwarded t SORM. Filing Deadline: The frm must be received by SORM nt later than the 5th calendar day after the first ntice f injury is reprted t the agency. Cmpleted by: This frm shuld be cmpleted by the persn giving the statement with assistance frm the Claims Crdinatr. Instructins: 1. Except fr the witness signature, the statement shuld be typewritten, if pssible. If it must be handwritten, PLEASE PRINT t ensure legibility. 2. Please prvide the SORM claim number, if knwn. 3. The witness may have actually seen the incident r may have acquired knwledge abut the accident frm anther surce. The witness infrmatin may relate t hw the incident ccurred r t smething else that is relevant. Check the first r secnd bx and fill in the blanks fllwing thse bxes, as apprpriate. Be specific and cmplete. Smetimes yu will be given a witness name but, when asked, denies any knwledge f the incident. In such a case the third bx shuld be checked. 4. If the space prvided n the frm is insufficient please attach additinal sheets. Be as specific and cmplete as pssible. Distributin: The Claims Crdinatr shall retain the riginal fr the agency file and fax r mail a cpy t: State Office f Risk Management PO Bx 13777 Austin, TX 78711 Fax: (512) 370 9025 Ntice: With few exceptins, an individual is entitled, upn request, t be infrmed abut the infrmatin a state gvernmental bdy cllects abut the individual. Under Sectins 552.021 and 552.023 f the Gvernment Cde the individual is entitled t receive and review the infrmatin and under Sectin 559.004 f the Gvernment Cde the individual is entitled t have the state gvernmental bdy crrect any infrmatin abut the individual that is incrrect. SORM 74 Rev 07/09