Sedgwick Claims Kit Missouri

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1 Sedgwick Claims Kit Missouri 2014 v2 P.O. Box Lexington, KY T: F: Toll Free:

2 Dear Insured: We would like to welcome you as a policyholder of Freestone Insurance Company. Sedgwick is your Claims Administrator and we are pleased to be able to provide you with workers compensation claims handling services. Please follow the below instructions for filing a new claim and note the claim kit attachment. Sedgwick Claim Kit Attachments Employer s First Report of Injury Form (F1) Facts for Injured Workers (WC-101) Authorization for Release and Use of Medical Information Claim Office Directory Provider Search Tool Job Aid Atlas General First Fill Temporary Pharmacy Card Atlas General Pharmacy Card Report of Injury Nurse Advice Poster To Report a Claim Phone: (855-7ATLAS7) Fax: Questions Linda Pettitt Client Services Associate Direct: Loss Runs Medical Provider Search https://www.viaoneprovidersearch.net/ User Name: Password: SedgwickCMS_123 (case sensitive) We appreciate your business and believe that communication is critical for successful claims administration. We encourage you to contact us if you have any questions.

3 BOLD BOXES ARE MANDATORY MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS COMPENSATION REPORT OF INJURY P.O. BOX 58 JEFFERSON CITY, MO (SEE INSTRUCTIONS ON PAGE 2) EMPLOYER (NAME, ADDRESS, INCL ZIP CODE) CARRIER ADMINISTRATOR CLAIM NUMBER REPORT PURPOSE CODE 00 GENERAL JURISDICTION MISSOURI INSURED REPORT NUMBER EMPLOYERS LOCATION ADDRESS (IF DIFFERENT) N/A JURISDICTION CLAIM NUMBER LOCATION # SIC CODE EMPLOYER FEIN PHONE # CARRIER CLAIMS ADMIN CARRIER (NAME, ADDRESS & PHONE NO.) CARRIER FEIN N/A POLICY PERIOD to CHECK IF APPROPRIATE POLICY SELF-INSURANCE NUMBER SELF INSURANCE CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO.) SEDGWICK CMS PO BOX LEXINGTON, KY ADMINISTRATOR FEIN AGENT NAME & CODE NUMBER NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH SOCIAL SECURITY # DATE HIRED STATE OF HIRE EMPLOYEE ADDRESS SEX MALE FEMALE UNKNOWN MARITAL STATUS UNMARRIED SINGLE DIVORCED MARRIED PHONE # # OF DEPENDENTS SEPARATED NCCI CLASS CODE UNKNOWN OCCUPATION JOB TITLE EMPLOYMENT STATUS WAGE RATE PER DAY WEEK MONTH OTHER # DAYS WORKED WEEK FULL PAY FOR DAY OF INJURY? DID SALARY CONTINUE? YES YES NO NO TIME EMPLOYEE BEGAN WORK AM DATE OF INJURY / ILLNESS TIME OF OCCURRENCE AM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN PM PM CONTACT NAME PHONE NUMBER TYPE OF INJURY ILLNESS PART OF BODY AFFE CTED OCCURRENCE DID INJURY ILLNESS EXPOSURE OCCUR ON EMPLOYER S PREMISES? YES NO DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED TYPE OF INUURY/ILLNESS CODE PART OF BODY AFFECTED CODE ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED, DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL CAUSE OF INJURY CODE DATE RETURN(ED) TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? YES NO WERE THEY USED? YES NO TREAT- MENT OTHERS PHYSICIAN HEALTH CARE PROVIDER (NAME & ADDRESS) WITNESS (NAME & PHONE #) HOSPITAL (NAME & ADDRESS) INITIAL TREATMENT 0 - NO MEDICAL TREATMENT 1 MINOR: BY EMPLOYER 2 MINOR CLINIC HOSPITAL 3 EMERGENCY CASE 4 HOSPITALIZED > 24 HOURS 5 FUTURE MAJ. MED. LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED DATE PREPARED PREPARER S NAME & TITLE PHONE NUMBER WC-1-EDI (09-02) AI

4 NOTE > This form is both the notice and report of injury as required by Section , RSMo. Injuries that require only first aid and result in no lost time need not be reported. Please mail this report to your WORKERS COMPENSATION INSURANCE CARRIER or Claims Administrator. If you are self-insured or are not under the Law and do not have an insurance carrier, mail this form to the Division. PRINT QUALITY > All reports of injury and supporting documents received by the Division will be processed electronically. All forms submitted to the Division MUST be of clear and legible quality. Handwritten forms will not be accepted. Computer generated forms shall use a minimum type size of 10 points. All documents not meeting the above criteria will be returned. DATE OF DEATH TO BE ANSWERED ONLY IN CASE OF DEATH EMPLOYEE S DEPENDENTS NAME OF DEPENDENT RELATION TO EMPLOYEE ADDRESS OF DEPENDENT ADDRESS CITY STATE ZIP CODE WC-1-EDI-2

5 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 described below, for purposes of administering my claim or request for reasonable accommodation. I understand that the information about me 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. ("Sedgwick") 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 any of the following: my request for reasonable accommodation; my workers compensation claim; my claim for disability benefits; my claim for bodily injury; my claim for personal injury; my claim for FMLA or my claim for dental benefits. My claim or request for reasonable accommodation involves the following condition: 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. Any person or facility that attends, treats or examines me, including but not limited to (specific name, if needed) is to make this information available to Sedgwick Claims Management Services, Inc. ( Sedgwick ) or any of its agents, representative or independent contractors; and B. When relevant to my claim, Sedgwick 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 may use my information obtained pursuant to this authorization in any other claim matter that Sedgwick may administer or handle related to me. 1

6 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. 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 at R Lexington, KY of my revocation and that my revocation shall be effective upon Sedgwick s 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 before it receives my revocation. 5. Processing of Claims. I understand that this Authorization is generally necessary for the processing of my claim or request for reasonable accommodation. Failure to sign this Authorization may impair or impede the processing of my claim or request for reasonable accommodation. 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 R Printed Name of Patient or Patient s Representative Representative s Relationship to Patient, if applicable Date Signed Sedgwick 7/2013 R X R R R Patient s Address X Patient s Social Security Number X First Day Absent R Date of Birth Sedgwick Claims Management Services, Inc. 2

7 AUTORIZACIÓN PARA USO Y DIVULGACIÓN DE INFORMACIÓN MÉDICA Yo, autorizo a cada una de las partes identificadas a continuación, para usar y divulgar cualquier y toda información médica y de salud inidentificable individualmente como mía, como se describe más adelante, para propósitos de administración de mi solicitud o petición para un acomodo razonable. Entiendo que la información sobre mí, que yo autorizo para uso y divulgación, puede estar sujeta a divulgación posterior, de acuerdo con los términos de esta Autorización, por parte del destinatario de ésta y que es posible que ya no esté protegida por las leyes y regulaciones federales o del estado sobre privacidad. Autorizo, específicamente, a médicos, enfermeras y hospitales para comunicar la información de salud o médica identificable individualmente como mía, a través de cualquier medio, incluidas comunicaciones escritas o telefónicas, o por entrevista directa, sea que este presente o se me haya notificado o no, de dichas comunicaciones, y por la presente, autorizo a Sedgwick Claims Management Services, Inc. ("Sedgwick ") para iniciar y realizar dichas comunicaciones, sea que este presente o haya recibido notificación de esto o no. 1. Qué información está incluida en esta Autorización? Esta autorización se aplica a toda la información, registros e informes médicos, de salud, sicológicos y/o psiquiátricos, incluida información sobre condiciones o enfermedades médicas o de salud preexistentes (a) que estén en existencia durante la validez de esta autorización (ver Punto 3) y (b) que estén relacionadas con cualquiera de las siguientes solicitudes: mi solicitud de acomodo razonable, mi solicitud de compensación del trabajador; mi solicitud de prestación por invalidez, mi solicitud por lesión corporal, mi solicitud por accidentes personales, mi solicitud de FMLA o mi solicitud de prestaciones dentales. Mi reclamo o pedido de internación razonable implica la siguiente condición: Mi información, que será divulgada, puede incluir, pero no se limita a, historia médica o de salud registros médicos, prescripciones, resultados de evaluaciones de diagnóstico, informes de rayos X y registros recibidos de otros prestadores de salud. Esta información puede incluir lo siguiente, si está directamente relacionada con las condiciones o enfermedades demandadas. Por favor, marque sí o no e inicial: resultados de pruebas de VIH, información sobre VIH o SIDA SÍ NO Inicial aquí Información siquiátrica. SÍ NO Inicial aquí Información relacionada con abuso de drogas o alcohol. SÍ NO Inicial aquí La Ley contra la discriminación de información genética de 2008 (GINA, por sus siglas en inglés) prohíbe a los empleadores y otras entidades que abarca el Título II de la GINA solicitar o requerir información genética de un individuo o miembro de la familia del individuo, excepto en los casos específicamente permitidos por esta ley. Para cumplir con esta ley, le solicitamos no brindar ninguna información genética cuando responda a esta solicitud de información médica. Información genética, como lo define la GINA, incluye la historia médica de la familia de un individuo, los resultados de pruebas genéticas del individuo o la de un miembro de su familia, el hecho de que un individuo o un miembro de la familia del individuo buscó o recibió servicio genéticos e información genética de un feto que el individuo o un miembro de la familia del individuo está gestando o un embrión en el vientre legalmente en el individuo o un miembro de la familia del individuo que recibe servicios reproductivos de asistencia. 2. Quién puede divulgar y recibir información bajo esta Autorización? A. Cualquier persona o instalación que me atienda, me proporcione tratamiento o me examine, incluyendo, sin carácter limitativo (nombre especifico, si es necesario) deberá poner esta información a disposición de Sedgwick Claims Management Services, Inc. ( Sedgwick ) o de sus representantes; y B. Cuando sea pertinente a mi solicitud, Sedgwick puede divulgar posteriormente (sin autorización ulterior) cualquier o toda información médica o de salud identificada individualmente como mía (fuese obtenida de acuerdo con esta autorización o, de lo contrario, de otra persona o entidad) a cualquiera de los siguientes: (a) cualquier persona o institución que me atienda, trate o examine; (b) cualquier persona o institución que influya en la determinación de mi solicitud o que coordine mis beneficios; (c) mi empleador y sus afiliados y sus representantes, contratistas independientes y prestadores de servicios que puedan recibir tal información de mi empleador hasta al grado que permite la ley federal o estatal, o (d) la Dirección del Seguro Social o el proveedor de seguro social o rehabilitación vocacional. Sedgwick puede usar mi información, obtenida de acuerdo con esta autorización, en cualquier otra materia de solicitud que Sedgwick pueda administrar o manejar en relación a mí. 3

8 3. Por cuánto tiempo es válida esta Autorización? Esta autorización es válida por el período de duración de mi(s) petición(es) y de cualquier petición relacionada futura; a menos que se requiera un período diferente de acuerdo con la ley federal o estatal correspondiente. 4. Revocación de esta Autorización. A menos que la ley federal o estatal establezca otra cosa, entiendo que puedo revocar esta autorización en cualquier momento al notificar, por escrito, a Sedgwick a R Lexington, KY de mi revocación y que ésta entrará en efecto una vez que Sedgwick haya recibido mi notificación de revocación. También entiendo que mi revocación de esta Autorización no tendrá ningún efecto sobre las acciones tomadas por Sedgwick antes del recibo de mi revocación. 5. Procesamiento de una Solicitud. Entiendo que esta Autorización, generalmente, es necesaria para el procesamiento de una solicitud o petición de acomodo razonable. El no firmar esta autorización puede perjudicar o impedir el procesamiento de mi solicitud o petición de acomodo razonable. 6. Denegación de Firma Además, entiendo que mis prestadores de atención médica no condicionarán mi tratamiento, pago, inscripción o elegibilidad, en caso de negarme a firmar esta Autorización. Entiendo que tengo derecho a solicitar y recibir una copia de esta autorización. Entiendo que tengo derecho de inspeccionar la información divulgada en cualquier momento. Una fotocopia de esta autorización será válida y aceptada con el mismo efecto que el original. Firma del Paciente o Su Representante R Nombre del Paciente o Su Representante Parentesco del Representante con el Paciente, si corresponde Día de Firma Sedgwick 7/2013 R X R R R Dirección del Paciente: X Número del Seguro Social del Paciente X Primer Día Ausente R Fecha de Nacimiento Sedgwick Claims Management Services, Inc. 4

9 To Report a Claim T: 855-7ATLAS7 ( ) F: Sedgwick Customer Service Linda Pettitt T: States Serviced Service Office / Contact Office Information Alabama Teresa Carden, Asst. Manager T: F: P.O. Box Lexington, KY Arizona Republic Underwriters program Arkansas California Republic Underwriters program Georgia Illinois Indiana Mississippi William Herring, Claims Director T: F: Teresa Carden, Asst. Manager T: F: Christopher Perez, AVP T: F: Teresa Carden, Asst. Manager T: F: Jennifer Krikie, Claims Director T: F: Jennifer Krikie, Claims Director T: F: Teresa Carden, Asst. Manager T: F: P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY /5/2014

10 Missouri Nevada New Jersey North Carolina South Carolina Tennessee Virginia Teresa Carden, Asst. Manager T: F: Richard Gomez, Manager T: F: Jennifer Keener, VP Operations T: F: Teresa Carden, Asst. Manager T: F: Teresa Carden, Asst. Manager T: F: Teresa Carden, Asst. Manager T: F: Carlos Alvarez, Asst. Manager T: F: P.O. Box Lexington, KY P.O. Box Las Vegas, NV P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY P.O. Box Lexington, KY /5/2014

11 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Provider Search Tool Access: Access Link Login Password Client https://www.viaoneprovidersearch.net/ SedgwickCMS_123 Provider Search: Search for Providers several ways: 1. Enter Zip Code, City, State or Distance 2. Enter a specific Address to narrow search results 3. Enter a Phone Number to search for a specific provider s phone number 4. Enter a License number or Tax Identification Number (TIN) 5. Enter partial or full spelling of Group or Provider Name 6. Check the First Treaters box only to receive first treating providers in the search results 7. Check the Hospitals / Facilities box only to receive hospitals / facilities in the search results 8. Check the First Treaters box and Hospitals / Facilities box to receive both types of providers in the search results 9. Check all three boxes to search all provider types and specialties Page 1 of 3

12 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS 10. Check the Other box and narrow the search results to specific specialties Network Dropdown Box: When searching in CA, TX or NY, the system will ask you to choose a network; then search. CA Network Options: Sedgwick National No MPN Sedgwick Standard MPN Sedgwick Extended MPN **Note provider directories for the MPN s listed below should be printed from: Sedgwick Standard MPN: Sedgwick Extended MPN: TX Network Options: Sedgwick National No HCN Coventry TX HCN SWMPN Southwest HCN NY Network Options: Sedgwick National Sedgwick DOC Sedgwick ROC The networks listed above differ depending on individual participation. The user must select the correct network before searching. Page 2 of 3

13 VIAONE PROVIDER SEARCH TOOL ACCESS INFORMATION AND INSTRUCTIONS Search Results: When the search results populate, you can view them by Specialty, Group or Provider. The number to the right of the specialty is a count of the number of providers / groups. To expand the specialties, click on the + symbol to the left of the specialty name To collapse the listing, click on the - symbol To filter the search results, use the filter button on the far right hand side of the screen. Click on the drop-down box next to the appropriate title Status: P = Provider is on a provider listing panel V= Provider has been validated within 6 months VP= Valid provider on a provider listing panel Page 3 of 3

14 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 Atlas General Insurance 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 Attention Pharmacists: Call 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 NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at 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: Call us: PMSI, Inc. All rights reserved. C1257B SCMS.

15 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 PMSI, Inc. All rights reserved. C1257B SCMS

16 Tarjeta temporal para surtir por primera vez sus recetas en farmacias Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o enfermedades laborales. Empleador: Imprima esta página inmediatamente después de recibir un aviso de lesión, complete la información que se encuentra a continuación y entréguesela a su empleado. Empleado lesionado: 1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con el trabajo, diríjase a una farmacia de la red Tmesys. 2. Entréguele esta página al farmacéutico. 3. El farmacéutico le surtirá la receta sin costo alguno. Prescription Card COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA) Sedgwick NOMBRE DEL EMPLEADO LESIONADO EMPLEADOR/OTRA ENTIDAD Atlas General Insurance At. farmacéuticos: Llamen al a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el número de ID para la adjudicación en línea de los beneficios aprobados para el trabajador lesionado. Tmesys es la administradora de beneficios de farmacia (PBM) asignada a este paciente. NÚMERO DE SEGURO SOCIAL Entregar directamente al farmacéutico FECHA EN QUE OCURRIÓ LA LESIÓN Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante 30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para encontrar farmacias cercanas a usted, llame al NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad) Farmacéutico: 1. Llame al servicio de asistencia de farmacias de Tmesys al Suministre la información que figura arriba. 3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación. Cómo encontrar una farmacia de la red Para encontrar una farmacia de la red, use uno de estos sencillos métodos: Visite alguna de las siguientes cadenas de farmacias: Walgreens Walmart Duane Reade Publix Rite Aid CVS Kroger Safeway Use nuestro localizador de farmacias en línea: Llámenos: PMSI, Inc. All rights reserved. C1257B SCMS

17 Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país. 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 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 *Lista sujeta a cambios. Ésta es sólo una lista

18 Print Area for P.O. Return Box Address Tampa, FL Logo 1 Box Size 1.25 x.5625 PERSONAL & CONFIDENTIAL Important Insurance Claim Document Enclosed Customer Address Box Size x Prescription Delivery By Mail Logo 2 Box Size 1.25 x.5625 Questions? Necesitas ayuda en español? Llame al In addition Pharmacy to Locations providing - currently access setup to for your 5 locations medications at a local pharmacy, Tmesys Box Size x.6875 can also deliver your medications to your home through our PMSI Mail Order Font size: Arial 7pt program at no cost. Using this convenient program means you will not have to drop off or pick up your prescription or wait in line while it is being fi lled. For more information 1 or to sign up, call or go to click on Mail Order Overview. Matrix measures x Card Logo Box Size 1.25 x.5625 Prescription Card DOI «DOI» ID# «subid» Keytag Info Name «Patientname» Box Size x.4375 Carrier «Carrier» Prescription Card DOI «DOI» ID# «subid» Keytag Info Name «Patientname» Box Size x.4375 Carrier «Carrier» Prescription Card NDC Envoy RxBin or RxPCN CAL or Envoy Acct.# Issuer (80840) Card Info Box Size 2.25 x.625 «DOI» «subid» «Patientname» «Carrier» Injury Date ID# Name Carrier/TPA.3125

19 Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call NDC Envoy RxBin or RxPCN CAL or Envoy Acct.# Issuer (80840) Attention Pharmacist: Tmesys is the workers compensation PBM for this patient. For questions regarding transmission, call NDC Envoy RxBin or RxPCN CAL or Envoy Acct.# Issuer (80840) Attention Cardholder: For questions regarding coverage or to fi nd a pharmacy call Tmesys at: or visit Attention Pharmacist: Tmesys is the designated workers compensation PBM for this patient. Call Tmesys with questions regarding transmission or rejection at: Note: Your use of this card is limited to those prescriptions medically related to an injury that is considered to be covered under the applicable state workers compensation law. IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS Taking Care of Using the Pharmacy Card Name Location 2 - Box Size x.1875 We want to make it easy for you to obtain the medication you need to recover from your work-related injury. Just follow these steps: 1. Activate the card by calling the toll-free number. 2. Separate the attached cards and place one in your wallet and one on your key ring. 3. Give a card to the pharmacist next time you have a new prescription or refill. 4. Your prescription will be filled at no cost. Finding a Pharmacy You can use any pharmacy that is part of the Tmesys network to fi ll your prescription and with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding a network pharmacy is simple! Use one of the options below: Visit one of the following pharmacy chains: Walgreens Walmart Duane Reade Publix Rite Aid Target Kroger Safeway Go to one of these nearby pharmacies: «Pharmacy1» Pharmacy Locations - currently setup for 5 locations «Pharmacy2» Box Size.4375 x 5.15 «Pharmacy3» Font Size = 7pt Look up a pharmacy on the website: click on Pharmacy Locator and choose a search option Call us toll free at <<PATIENTNAME>>.375 Name Location 1 - Box Size x Matrix measures x PMSI, Inc. All Rights Reserved. SCMSMOD

20

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