Workers Compensation Manager s Guide. Human Resources Contacts

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Karin Doyle
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Location: Preferred Provider Clinic: Workers Compensation Manager s Guide Activity Checklist: Secure medical treatment or first aid for the injured employee immediately.

1 Location: Preferred Provider Clinic: Workers Compensation Manager s Guide Activity Checklist: Secure medical treatment or first aid for the injured employee immediately. Direct the employee to the designated clinic (see Preferred Provider Network attached), if the state permits (Not permitted in IL & TX). Provide the employee with a copy of the Authorization for Initial Medical Treatment form and fax it to the treating clinic. Instruct the employee to return to the office after the doctor s visit with the medical paperwork provided by the physician. Fax or the Authorization for Initial Medical Treatment, the First Report of Injury and any medical paperwork provided by the employee to Human Resources within 24 hours. If the employee returns to the site with restrictions, work with Human Resources to find a temporary transitional-duty position that accommodates the restrictions indicated by the doctor. Supervisor s Responsibilities: Report ALL injuries immediately to Human Resources. Treat employees with concern and respect. Accompany the employee to the appropriate medical provider, if necessary. Note: If it is after hours or the weekend, be sure a phone message is left for Human Resources. Ensure employees are not asked to work beyond the restrictions established by the treating physician. Work with your Human Resources contact to strategize how to accommodate return-to-work restrictions reasonably and promptly. Human Resources Contacts California, Co. & North East Maritza Riquelmy Director of HR (813) Florida Denise Vining HR Business Partner (813)

2 Authorization for Initial Medical Treatment The referenced employee has reported sustaining a work-related injury/illness. You are authorized to provide reasonable and necessary treatment for conditions related to the reported injury/illness. Your charges for reasonable and customary services related to the work injury will be paid, per the workers compensation reasonable and customary billing guidelines for your state. Follow-up care and/or referral to specialist will require authorization from our workers compensation insurance carrier. To facilitate prompt payment, a complete copy of this form should be attached to your completed billing document and submitted to: Sedgwick Claims Management Services, Inc. Policy Number: CA Phone Number: Billing Address: PO Box Lexington, KY Should you need to contact the Human Resources Department of the Employer, please call: (All Locations) RICHMAN PROPERTY SERVICES, INC. HAS VARIOUS TRANSITIONAL DUTY POSITIONS AND WILL ASSIST THE EMPLOYEE IN RETURNING TO WORK, IF AT ALL POSSIBLE, EVEN IN A LIMITED CAPACITY. DATE: TO BE COMPLETED BY THE EMPLOYER FROM: Richman Property Services, Inc. TO: NAME OF HOSPITAL, CLINIC, OR DOCTOR: PHONE NUMBER: HUMAN RESOURES BUSINESS PARTNER: Maritza Riquelmy-Romero Denise Vining ADDRESS: 4350 W Cypress Street Suite 340 Tampa, FL PHONE NUMBER: (All Locations) ASSOCIATE NAME: FAX NUMBER: (All Locations) REPORTED INJURY/ILLNESS AND PART OF BODY: 4350 W Cypress Street Suite 340 Tampa, FL 33607

4 Workers' Compensation In-Network Providers Policy Number: CA Name Specialty Address City County State Zip Phone Fax Physician Immediate Care Park Ridge Urgent Care Clinic 800 N Larkin Ave Joliet Will IL Physician Immediate Care Park Ridge Urgent Care Clinic 1360 Houbolt Rd Joliet Will IL Hickbottom, Ronald, MD Occupational Medicine 2100 Glenwood Ave Joliet Will IL Hickombottom, Ronald A., MD Occupational Medicine 2100 Glenwood Ave Joliet Will IL

8 Renuncia de Tratamiento Medico (Nombre de la Compania) se interesa en el bienestar de todos sus empleados. En el caso que usted no desee recibir tratamiento medico, necesitamos documenta que (Nombre de la Compania) no ha influido en ninguna forma su decision de no solicitor tratamiento medico. Empleado: Fecha del Incidente: Descripcion del Incidente: Descripcion de la Herida: Mi firma es confirmacion de que he voluntariamente renunciado tratamiento medico para el antedicho incidente. Si se determina que necesito tratamiento medico, consultare con mi Injury Counselor antest de solicitor tratamiento, a menos que se requiera tratamiento medico de emergencia. Firma del Empleado: Fecha:

9 Medical Treatment Waiver Richman Property Services, Inc. is concerned with every employee s well-being. In the event you elect not to seek medical attention, we need to document that Richman Property Services, Inc. has not influenced, in any way, your decision to not seek treatment. Employee: Date of Injury: Description of Accident: Description of Injury My signature confirms that I have voluntarily waived medical care due to the injury indicated above. Should it later be determined that I require medical care, I will consult with my Injury Counselor prior to seeking treatment, unless emergency treatment is required. Employee s Signature: Date: A signed copy of this form should be given to the employee.

SCHERTZ-CIBOLO-UNIVERSAL CITY ISD WORKERS' COMPENSATION OVERVIEW

SCHERTZ-CIBOLO-UNIVERSAL CITY ISD WORKERS' COMPENSATION OVERVIEW As a District, we strive very hard to provide a safe environment for our employees and students. It is very important that we adhere to