1 Dear AmeriHealth Casualty Client: Welcome to AmeriHealth Casualty Services! It is our goal to assist you in managing the medical and financial aspects of work injuries. We have designed a program that provides quality care to your injured employees at a reasonable cost. Enclosed please find: A listing (panel) of approved treatment providers in your area. You must post this panel in some location that is accessible to all employees, such as a lunch room or company bulletin board. Make sure all employees know where this panel is posted. Injured employees are obligated to treat with one of these physicians for the first 90 days after a work injury. What Happens If I Get Hurt At Work? helps your employees understand their rights and responsibilities under Pennsylvania s Workers Compensation Act. Distribute this form to all your employees and have them sign the acknowledgment form at the bottom. Keep one copy in the employee s personnel file and give the other copy to the employee for his/her records. When an injury occurs, send/fax a copy of this signed acknowledgment with the claim forms. A claim form is enclosed. Please photocopy this form. Complete it whenever a work injury occurs and fax it to us at (888) A Medical Authorization should be signed by the injured employee and faxed to us with the claim. This authorizes us to obtain timely medical reports and facilitate early return to work. What Do I Do If My Employee Gets Hurt At Work? helps remind you of what to do if one of your employees is injured on the job. Copies should be provided to all supervisors. Injury cards should be given to employees when they are injured. These cards provide billing information that the panel doctors will need to process the claim. As an employer in Pennsylvania, it is important that you have an understanding of the state s Workers Compensation Act. You can contact us if you need a copy of the act. Remember: It is your responsibility to know the act and to comply with its provisions. We are looking forward to working with you to manage your workers compensation claims and costs. Please do not hesitate to contact us at with any questions or concerns.
2 Mail correspondence to: AmeriHealth Casualty Services 1717 Arch Street 45 th Floor Philadelphia, Pennsylvania Report a claim by Phone or Report a claim by fax at After hours or emergency only Claim reporting questions are to be directed to: Jada Patrick at (215) Kelly Holdofsky, Claim Supervisor (215) Kristen Hayes, Claim Supervisor (215) Bridget Chow, Manager of Client Services (215) Brian Gossner, Client Services (215) Robert Schiller, Director of Claim Operations (215)
3 Authorization to Release Medical Information I hereby authorize any physician, nurse or other health care professional who has attended me, or any hospital at which I have been confined to furnish to AmeriHealth Casualty Services or an authorized representative, any and all information which may be requested regarding my physical or mental condition and treatment rendered therefore and, if necessary, to allow them or any physician appointed by them to examine any x-rays take of me or records regarding my physical or mental condition or treatment. A photocopy of this instrument may be used instead of the original. La Autorización a Soltar a Informacion Médico Por este medio autorizo a cualquier médico, cualquiera enfermera u otro profesional de cuidado de la salud que me ha asistido a mí, o cualquier hospital en el cual he estado recluido para proveer para AmeriHealth Casualty Services o un representante autorizado, cualquier información que puede ser demandado referente a mi condición física o mental y que mi tratamiento dado por esto y, si necesario, a permitirlos a ellos o cualquier médico señalado por ellos a examinar cualquier tome radiográfias de mí o los registros estimando mi condición física o mental o el tratamiento. Una fotocopia de esta forma puede ser usada en lugar del original. Date Employee's Name (Print) Employee's Signature Employee's Date of Birth Employee's Social Security Number Employee's Home/Cell Phone Number La fecha Nombre del Empleado (la Impresión) Signatura del Empleado Fesha de Nacimiento del Emploado El Numero de Seguro Social del Empleado El Número de Teléfono de Casa/Celular del Empleado
4 Que Sucede Si Se Hiere En El Trabajo? Hasta en los lugares de trabajo mas seguros, lesións pueden ocurrir. Lo siguies lo que debe hacer si se hiere en el trabajo: 1. Notifique a su supervisor inmediatamente. El / Ella se asegurará de que uste reciba asistencia médica si usted la necesita, y pondra una demanda de la remuneración de trabajadores en su favor. 2. Para tratamiento de emergencia, usted debe ir a la sala de emergencia más cercana. Para tratamiento que no sea emergencia, elija a uno de los médicos del panel. Si usted no tiene una lista del panel, ve a su supervisor o Recursos Humanos. Cualquier tratamiento adicional se debe proporcionar por uno de los proveedores aprobados en la lista del panel. 3. Según el Acto de la Remuneración de Trabajadores de Pennsylvania, usted debe tartar con un proveedor del panel para los primeros 90 días. Cualquier tratamiento que no sea autorizado o tratamiento fuera del panel será su responsabilidad financiera y puede comprometer su demanda. Después de 90 días usted puede tratar con un proveedor que usted elija, pero usted debe notificar a su patron en escrito dentro de 5 días de la primera visita o el tratamiento se convierte en su responsabilidad financiera. 4. El medico del panel evaluará su lesion y determinará si usted puede volver al trabbajo. Si se determina que usted no debe volver al trabajo, notifique a su supervisor inmediatamente. 5. Usted debe guarder citas fijadas con su proveedor del tratamiento. Sip or cualquier razón, usted no esta satisfecho con el tratamiento que está recibiendo, por favor llame a AmeriHealth al Después de horas de oficina regulares, llame al Nuestros ajustadores de reclamaciónes y encargados de casos medicos están disponibles para hablar de su reclamación y para asegurar que usted reciba el cuidado razonable y necesario para su lesion. Reconocimiento En conformidad con el Acto de la Remuneración de Pennsylvania, reconozco que me han informado mis derechos y he recibido una copia del panel designado del proveedor del cuidado medico cuál fué diseñado por los servicios de AmeriHealth Casualty para mi patrón, (nombre de la compañia). Comprendo que cualquier lesión o enfermedad relacionado al trabajo debe ser reportada inmediatamente a mi supervisor y, con exepción del cuidado de emergencia, debo tratar con uno de los proveedores en el panel para los primeros 90 diás después de mi lesión. Comprendo que si trato fuera de este panel sin la autorización apropiada, mi patrón tiene el derecho de rechazar el pago para ese tratamiento. Si requiero tratamiento después de 90 diás, entiendo que puedo elegir un proveedor fuera del panel, pero debo notificar a mi patrón dentro de 5 diás de la primera visita a este proveedor. Comprendo que si se recomienda cirugía debo obtener una segunda opinión con un médico de mi elegir. Si defiere la segunda opinión, puedo elegir el curso de tratamiento que deseo, pero ese tratamiento debe ser rendido por uno de los proveedores del panel si estoy dentro de los primeros 90 diás después de la lesión. Firma Fecha Copia 1: Recursos Humano Copia 2: Empleado
5 What Do I Do If My Employee Gets Hurt At Work? Even at the safest of workplaces, accidents can occur. Here s what to do if one of your employees is injured on the job: 1. The employee should notify his/her supervisor immediately. The supervisor will complete an accident report and ensure that medical care with a panel doctor is rendered if needed. The supervisor is responsible for completing the workers compensation claim form. The completed form should be faxed to the number on the top of the form along with a copy of the acknowledgment statement that the employee signed when his benefits were explained to him. This acknowledgment statement is located at the bottom of the What Happens If I Get Hurt At Work form and a copy with the employee s signature should be in his/her personnel file. 2. For emergency care you should call 911 or have someone accompany the injured employee to the closest emergency room. Any follow-up care should be provided by one of the facilities on your workers compensation panel list. 3. For non-emergencies, the employee should choose one of the panel doctors. You should give the injured employee a copy of the panel at this time. 4. According to Pennsylvania s Workers Compensation Act, injured employees must treat with a panel provider for the first 90 days. Any unauthorized treatment or treatment outside the panel will be the employee s financial responsibility and may jeopardize the workers compensation claim. 5. The panel physician will evaluate the employee and determine if further testing is needed. He/She will also determine if it is safe for the employee to return to work. If the employee is not returned to work, he/she must notify you immediately. 6. The injured employee must keep scheduled appointments with the chosen treatment provider. If, for any reason, the employee is unsatisfied with the care he/she is receiving, please call us at After regular business hours, please call
6 What Happens If I Get Hurt At Work? Even at the safest of workplaces, injuries can occur. Here s what to do if you are injured at work: 1. Notify your supervisor immediately. He/She will ensure that you receive medical care if you need it and will file a workers compensation claim on your behalf. 2. For emergency care you should go to the closest emergency room. Any followup care should be provided by one of the approved facilities on your workers compensation panel list. For non-emergencies, choose one of the panel doctors. If you do not have a panel list, see your supervisor or Human Resources. 3. According to Pennsylvania s Workers Compensation Act, you must treat with a panel provider for the first 90 days. Any unauthorized treatment or treatment outside the panel will be your financial responsibility and may jeopardize your claim. After 90 days you may treat with a provider of your choice but you must notify your employer in writing within 5 days of the first visit or the treatment becomes your financial responsibility. 4. The panel physician will evaluate your injury and determine if it is safe for you to return to work. If you are not returned to work, notify your supervisor immediately. 5. You must keep scheduled appointments with your treatment provider. If, for any reason, you are unsatisfied with the care you are receiving, please call AmeriHealth at After regular business hours, call Our claims adjusters and medical case managers are available to discuss your claim and to ensure that you receive reasonable and necessary care for your work injury Acknowledgment In compliance with Pennsylvania s Workers Compensation Act, I acknowledge that I have been informed of my rights and have received a copy of the designated health care provider panel which was designed by AmeriHealth Casualty Services for my employer,. I understand that any work (Name of Company) related injury or illness is to be immediately reported to my supervisor and, with the exception of true emergency care, I am to treat with one of the providers on the panel for the first 90 days after my injury. I understand that if I treat outside this panel without proper authorization, my employer has the right to refuse payment for that care. Should I still require treatment after 90 days, I understand that I may choose a non-panel provider but that I must notify my employer within five days of the first visit to this provider. I understand that if surgery is recommended I may seek a second opinion with a physician of my choosing. If the second opinion differs, I may choose the course of treatment I wish to follow but that treatment is to be rendered by one of the panel providers if I am within the first 90 days after injury. Signature Date
7 What s So Special About AmeriHealth s Network of Physicians? All network providers: 1. Are subjected to a rigorous credentialing process. 2. Must be approved by a credentialing board before they are admitted to the network. 3. Agree to see injured employees within 24 hours. 4. Have a strong working knowledge of workers compensation laws. 5. Agree to provide specific work restrictions, facilitating early return to work. 6. Agree to provide medical reports in a timely fashion. 7. Agree to accept a significant discount below the workers compensation fee schedule or the usual, reasonable or customary fee, dependent on jurisdiction, thus helping you keep your medical costs down. 8. Understand the importance of providing treatment plans to our Nurse Case Managers. 9. Agree to a second surgical opinion in all but true emergency cases. 10. Agree to send all medical bills directly to us.
8 Workers Compensation Information (1) The workers compensation law provides wage loss and medical benefits to employees who cannot work, or who need medical care, because of a work-related injury. (2) Benefits are required to be paid by your employer when self-insured, or through insurance provided by your employer. Your employer is required to post the name of the company responsible for paying workers compensation benefits at its primary place of business and at its sites of employment in a prominent and easily accessible place, including, without limitation, areas used for the treatment of injured employees or for the administration of first aid. (3) You should report immediately any injury or work-related illness to your employer. (4) Your benefits could be delayed or denied if you do not notify your employer immediately. (5) If your claim is denied by your employer, you have the right to request a hearing before a workers compensation judge. (6) 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 , telephone number within Pennsylvania (800) ; telephone number outside of this commonwealth (717) : TTY (800) (for hearing and speech impaired only): PA Keyword: workers comp.
VICTOR VALLEY UNION HIGH SCHOOL DISTRICT 16350 Mojave Drive Victorville, CA 92395 (760) 955-3201 SUPERVISOR INSTRUCTIONS FOR MANAGING INJURED EMPLOYEES In the event of a life threatening emergency, immediately
Markel Insurance Company/*FirstComp Medical Provider Network (MPN) Markel Insurance Company/FirstComp offer their policyholders the efficiencies of Medical Provider Networks (MPN) for the benefit of the
Sedgwick Claims Kit Georgia 2014 v2 P.O. Box 14484 Lexington, KY 40512-4484 T: 865-583-8300 F: 865-583-8310 Toll Free: 800-773-4840 Dear Insured: We would like to welcome you as a policyholder of Freestone
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,
Employee Claim C-3 State of New York - Workers' Compensation Board Fill out this form to apply for workers' compensation benefits because of a work injury print neatly. This form may also be filled out
STATE OF NEW YORK WORKERS COMPENSATION BOARD 100 BROADWAY-MENANDS ALBANY, NY 12241 (877) 632-4996 You were injured at work. What now? The New York State Workers Compensation Board has received notice you
New Employee Paperwork Summary EMPLOYEE NAME WWID The following forms must be signed and collected at New Employee Orientation: Completed by New Hire 1. Appendix A / Employment Agreement 2. Information
Attorneys at Law Información del Cliente Fecha: Fecha del Accidente: Ubicación: Ciudad/Estado/Condado Nombre completo del cliente: Adulto [ ] Menor de Edad [ ] Nombre del Representante Personal: Dirección:
INJURY REPORTING FORMS County of Los Angeles Return to Work Program RECEIPT OF EMPLOYEE PACKET This packet should be given to the employee when a potential work related accident or injury has been reported,
P.. Box 881236, San Francisco, CA 94105 Phone: (888) 495-8949 bhhc.com Dear Policyholder: Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We
County of San Diego, Health and Human Services Agency (HHSA) County Medical Services (CMS) Program Guide Letter County Medical Services (CMS) Program Update and Termination Number Page of the Low Income
YOUR WORKERS COMPENSATION POLICY GUIDE Florida Thank you for choosing Builders Mutual Insurance Company as your commercial insurance carrier. As the industry experts, we pride ourselves in providing top
Notice of Privacy Practices Notificación de prácticas de privacidad Effective Date: September 23, 2013 This is a notice describes how medical information about you may be used and disclosed and how you
Guide to Workers Com for State of California pensation Employees Helpful information you should know if you are injured on the job or become ill due to your job. Questions and Answers What is State Compensation
United I.S.D. Student Extra-Curricular Insurance Sponsor Kit 7-01-10 Sponsor Kit (Student Extra-Curricular Insurance) The following forms make up the sponsor kit for extra-curricular activities. Attached
Guía 1 de la Unidad de Información y Asistencia Cómo presentar un formulario de reclamo de compensación para trabajadores Utilice un formulario de reclamo para informar de una lesión o enfermedad en el
Work-Related Injury Reporting The most important step in dealing with an employee injured on the job is getting him or her appropriate medical care. Next is making certain that the claim is reported immediately.
Long Island Bus Represented Employees Only Short-Term Disability Claim Forms Hartford Life Insurance Company PO Box 2999 Hartford, CT 06104-2999 800-454-7020 CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
ATTACHMENT I WORKERS' COMPENSATION BENEFITS MEDICAL CARE. Your employer will arrange for medical care, and all costs are paid directly by your employer's insurance company, so you should never see a bill.
DIGESTIVE HEALTH CENTER Specialists who help you feel your best Steven A. Fein, M.D., FACG Julie Erps, PA-C 4001 Preston Ave, Suite 125 Call (713) 946-9513 Fax (713) 946-7210 PATIENT INFORMATION Please
Homestead Program 14921 W Camdon Drive Casa Grande, AZ 85222 Phone: (520) 876-5293 Fax: (520) 876-5613 Homestead North Program 7345 N Hidden Hills Road Flagstaff, AZ 86001 Phone: (928) 526-2383 Fax: (926)