The following state forms have been included in your claims kit packet:

Transcripción

1 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, we want you to have all the information you might need in the event one occurs. Enclosed is our Workers Compensation Injury Reporting Kit that contains the Wisconsin state-mandated forms and a step-by-step process to follow in case an employee sustains an injury. When a claim occurs, see the attached instructions for reporting a claim to our Claims Intake Unit. The contact information for the Claims Intake Unit is listed on the How to File an Injury form included in this packet. The Tower Group claim office which will be handling your claim is located in Chicago, Illinois. Once reported, a claims representative will contact you to obtain additional information about the injured employee and to answer any questions that you might have regarding the Wisconsin workers compensation process. The following state forms have been included in your claims kit packet: 1. Wisconsin Form WKC-12- First Report of Injury (FROI) This form must be completed when an employee reports a work related injury or illness. For any accident disease causing disability beyond the 3 rd day after time is lost due to injury. Mandatory reporting is required within one (1) day for injury causing death. 2. Wage Statement- Please complete and send a copy of employees Wage Statement to the Tower Group Companies at the time of the injury. 3. Wisconsin Form WKC-9488-E Medical Authorization- Consent Form for Release of Medical Information- English/Spanish- this form is to be signed by the injured employee and sent to Tower Group Companies. It is to provide consent for the release of medical information. We thank you for your business and look forward to being of service to you. Very truly yours, Tower Group Companies CL TGC (08/10)

2 HOW TO FILE A WORK INJURY OR ILLNESS CLAIM Workers compensation claims can be reported in several different ways, you can: Complete and submit the Wisconsin Form WKC-12- First Report of Injury (FROI) and submit the form via one of the following: the completed form to rthclaims@twrgrp.com. This is the preferred method of reporting an injury. Fax to Tower Group Companies at Call the Tower Group Companies Claims office at By contacting your broker directly and providing the appropriate first report information. For injuries occurring after normal business hours, please call The after hours telephone number for reporting claims provides the opportunity to report a claim 24 hours a day 7 days a week. Loss details will be gathered to determine if an emergency exists and if an immediate field contact is indicated. IN02 08/08

3 EMPLOYER S FIRST REPORT OF INJURY OR DISEASE Fatal Injuries: Employers subject to ch.102, Wis. Stats., must report injuries resulting in death to the Department and to their insurance carrier, if insured, within one day after the death of the employee. Non-Fatal Injuries: If the injury or occupational illness results in disability beyond the three-day waiting period, the employer, if insured, must notify its insurance carrier within 7 days after the injury or beginning of disability. Medical-only claims are to be reported to the insurance carrier only, not the Department. Electronic Reporting Requirement: All work-related injuries and illnesses resulting in compensable lost time, with the exception of fatalities, must be reported electronically to the Department via EDI or Internet by the insurance carrier or self-insured employer within 14 days of the date of injury or beginning of disability. Employer may fax claims for fatal injuries to the Imaging Fax Server number on this form. Provision of your Social Security Number (SSN) is voluntary. Failure to provide it may result in an information processing delay. Personal information you provide may be used for secondary purposes [Privacy Law, s (1)(m), Wisconsin Statutes]. (Please read the instructions on page 2 for completing this form) Employee Name (First, Middle, Last) Social Security Number Sex INJURY INFORMATION WAGE INFORMATION EMPLOYER EMPLOYEE - - M F Employee Street Address City State Zip Code - Birthdate Date of Hire County and State Where Accident or Exposure Occurred? Department of Workforce Development Worker s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI Imaging Server Fax: (608) Telephone: (608) DWDDWC@dwd.wisconsin.gov Employee Home Telephone No. ( ) - Occupation Employer Name WI Unemployment Ins. Acct No. Self-Insured? Nature of Business (Specific Product) Yes No Employer Mailing Address City State Zip Code - Employer FEIN - Name of Worker s Compensation Insurance Co. or Self-Insured Employer Insurer FEIN - Name and Address of Third Party Administrator (TPA) Used by the Insurance Company or Self-Insured Employer TPA FEIN - Wage at Time of Injury Specify per hr., wk., mo., yr., etc. In Addition to Wages, Meals No. of Meals/wk. $ Per: Check Box(es) if Room No. of Days/wk Employee Received: Tips Avg. Weekly Amt. $ Is Worker Paid for Overtime? Yes No If Yes, After How Many Hours of Work Per Week? For the 52 Week Period Prior to the Week the Injury Occurred, Report Below the Number of Weeks Worked in the Same Kind of Work, and the Total Wages, Salary, Commission and Bonus or Premium Earned for Such Weeks. No. of Weeks: Gross Amount Excluding Tips: $ If Piece-Work, No. of Hrs. Excluding Overtime: Employee s Usual Work Schedule When Injured: : AM PM Employer s Usual Full-Time Schedule for This Type of Work at Time of Employee s Injury: Part-Time Employment Information: Injury Date Are there Other Part-Time Workers Doing the Same Work With the Same Schedule? Yes No If yes, how many? Time of Injury : AM : PM Start Time Hours Per Day Hours Per Week Days Per Week Number of Full-Time Employees Doing The Same Type Of Work: Last Day Worked Date Employer Notified Date Returned to Work Estimated Date of Return Did Injury Occur Because of: Substance Failure to Use Failure to Abuse Safety Devices Obey Rules Did Injury Cause Death? Date of Death Was This a Lost Time or Other Yes No Compensable Injury? Yes No Was Employee Treated in an Emergency Room? Yes No Was Employee Hospitalized Overnight as an In-Patient? Yes No Name and Address of Treating Practitioner and Hospital: Case Number from the OSHA Log: Injury Description - Describe Activities of Employee When Injury or Illness Occurred and What Tools, Machinery, Objects, Chemicals, Etc. Were Involved. What Happened to Cause This Injury or Illness? (Describe How The Injury Occurred) What Was The Injury or Illness? (State the Part of Body Affected and How It Was Affected) Report Prepared By Work Phone Number ( ) - Position Date Signed WKC-12 (R. 02/2009) SEND REPORT IMMEDIATELY - DO NOT WAIT FOR MEDICAL REPORT

4 EMPLOYER AND INSURANCE CARRIER INSTRUCTIONS The employer must complete all relevant sections on this form and submit it to the employer s worker s compensation insurance carrier or third party claim administrator within seven (7) days after the date of a work-related injury which causes permanent or temporary disability resulting in compensation for lost time. The employer s insurance carrier or the third-party claim s administrator may request that this form also be used to immediately report any injury requiring medical treatment, even though it does not involve lost work time. For any work injury resulting in a fatality, the employer must also submit this form directly to the Department of Workforce Development within 24 hours of the fatality. An employer exempt from the duty to insure under s , Wis. Stats., and an insurance carrier administering claims for an insured employer are required to submit this form to the Department of Workforce Development within 14 days of the date of work injury. MANDATORY INFORMATION In order to accurately administer claims, each of the following sections of this form must be completed. The First Report of Injury will be returned to the sender if the mandatory information is not provided. Employee Section: Provide all requested information to identify the injured employee. If an employee has multiple dates of employment, the Date of Hire is the date the employee was hired for the job on which he or she was injured. Employer Section: Provide all requested information to identify the injured worker s employer at the time of injury. Provide the name and Federal Employer Identification Number (FEIN) for the insurance carrier or selfinsured employer responsible for the worker s compensation expenses for this injury. Also identify the third party claim administrator, if one is used for this claim. Wage Information Section: Provide the information requested regarding the injured employee s wage and hours worked for the job being performed at the time of injury. Injury Information Section: Provide information regarding the date and time of injury. Provide a detailed description of the injury, including part of the body injured, the specific nature of the injury (i.e., fracture, strain, concussion, burn, etc.) and the use of any objects or tools (i.e., saw, ladder, vehicle, etc.) that may have caused the injury. Provide the name of the person preparing this report and the telephone number at which they may be reached, if additional information is needed. This form was designed to include information required by OSHA on form 301. If this section is completed and retained, the employer will not have to complete the OSHA 301 form.

5 W AGE S TATEMENT Employer: Employee: Please provide the 52 weeks of wages prior to the date of injury of Date employee ceased to work: Number of Hours employee is scheduled to work per week: Is employee paid by hour, day, week or month Date Hired Claim Number At what rate: Does Employee work Overtime Yes No If yes, is Overtime mandatory Yes No State the date and amount of any pay increases during the past 52 weeks Date Amount Date Amount Date Amount Date Amount Dates Incl of each Week Pd Hrs Wkd Regular Pay Overtime Pay Dates Incl of each Week Pd From To Yr From To Yr Hrs Wkd Regular Pay Overtime Pay SUBTOTAL SUBTOTAL GRAND TOTAL This is a correct statement of Employee s earnings as actually taken from Payroll Records Employer s Signature Title Date

6 Voluntary and Informed Consent for Disclosure of Health Care Information The provision of your social security number is mandatory under Wisconsin Statutes and will be used to identify the claimant. Failure to provide it may result in penalties or delayed payment of benefits. Personal information you provide may be used for secondary purposes [Privacy Law, s (1)(m), Wisconsin Statutes]. Department of Workforce Development Worker s Compensation Division 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI Telephone: (608) Fax: (608) DWDDWC@dwd.wisconsin.gov By law, all health care providers must provide to any employee, employer, worker's compensation insurer or their representative any information reasonably related to any alleged work injury. However, determining the relationship of prior medical records to a work injury can be difficult and time-consuming. Therefore, to assist in the timely investigation of your claim, this document authorizes the health care provider to release medical information without attempting to determine the extent of its relationship to your alleged work injury. You are not required to sign this document. You may refuse to sign this document without jeopardizing your right to collect worker's compensation benefits. However, by assisting in the investigation of your claim, you are likely to receive benefits quicker than if you refuse to authorize the release of medical information. Health Care Provider Name Street Address P. O. Box City State Zip Code Patient (Employee) Name Employer Name Patient Social Security Number - - Patient Birth Date WC Claim No. The patient named above hereby authorizes the health care provider named above to disclose all records checked below in its possession relating to the patient's health, treatment and evaluation to: Name and Address of Party Authorized to Receive Protected Information or its designated representatives, and to furnish to them a legible, certified duplicate of all records, writings, reports, test results and x-rays in its possession containing such information. This authorization includes all records, reports, correspondence, or other materials in the possession of the health care provider authorized, even if those materials were not generated by the health care provider, and the redisclosure of such materials is hereby authorized. This release is for use in the investigation, preparation, evaluation, and/or hearing of the worker's compensation claim described above. CHECK ONE: A. Physical Only. Release all records, correspondence, and any other information from whatever source regarding the patient's physical health, treatment and evaluation including, but not limited to, any made or provided by any physician, nurse, chiropractor, osteopath, dentist, physical therapist, hospital, or any other health care provider. This consent constitutes a waiver of any privilege created by state or federal statute, regulation, rule or other authority, including but not limited to Wis. Stat and , and 45 C.F.R B. Physical and Other. Release all records, correspondence, and any other information from whatever source regarding the patient's physical and mental health, drug and alcohol abuse, HIV and AIDS tests, treatment, and evaluation including, but not limited to, any made or provided by any physician, psychiatrist, psychologist, nurse, chiropractor, osteopath, dentist, physical therapist, hospital or any other health care provider. This consent constitutes a waiver of any privilege created by state or federal statute, regulation, rule or other authority, including but not limited Wis. Stat , , and , 42 C.F.R., Chap. 1, subpart C, 2.31 and 45 C.F.R Patient Signature (or Person Authorized to Sign for Patient) for Option B Patient Signature (or Person Authorized to Sign for Patient) Date WKC-9488-E (R. 03/2009) Page 1 of 2

7 In signing this consent form, I acknowledge that I understand that: I am authorizing release of the records and information listed above. I am waiving any privilege that may otherwise prevent disclosure of the records and information listed above. I understand that the health care provider named above, whom I am authorizing to disclose my protected health information, may not condition my treatment, payment, enrollment or eligibility for benefits (if applicable) on whether I sign this authorization, except: (1) if my treatment is related to research, or (2) health care services are provided to me solely for the purpose of creating protected health information for disclosure to a third party. I may revoke this authorization at any time by a written request to the party authorized above to receive information, except that the party authorized above to receive such information may rely upon any personal health information received before the revocation of this authorization. I may obtain a copy of the disclosed records and information, upon written request to the party authorized above to receive information, at no charge to me. My personal health information disclosed pursuant to this authorization may be redisclosed and may no longer be protected by federal law. My personal health information may be released to any of the following: the employer, the worker s compensation insurer, the Department of Workforce Development, other parties to this matter or their attorneys; the Labor and Industry Review Commission; any court on any action or proceeding relating to this matter; experts retained or consulted by any party; and any of their agents, employees, or representatives. I specifically authorize and consent to any such disclosure and redisclosure. I am entitled to a copy of this consent form after I sign it. If you have any questions about this document, you should contact the Worker's Compensation Division at (608) You should not sign this document if the name of the health care provider is blank. This consent is subject to revocation at any time. If not revoked, this consent is effective for two (2) years from date signed. This authorization expressly waives any requirement that it must be used within a certain number of days after the date of signing, or that it must be dated within any time period before the date it is used. This authorization shall also extend to records of future treatment, after the date of signing of this authorization, as long as such treatment occurs while this authorization is still in effect. A photocopy copy shall be as valid as the original. Patient Signature (or Person Authorized to Sign for Patient) Date If not signed by patient, authority/designation to sign is based on the fact that the patient is A minor Incompetent Disabled Deceased Other: Page 2 of 2

8 Consentimiento Voluntario e Informado para la Divulgación de Información de Atención Médica Es obligatorio proporcionar el número de la seguridad social bajo los Estatutos de Wisconsin y se utilizará para identificar a la persona que ponga el reclamo. El no proporcionarlo puede resultar en sanciones o en el retraso del pago de beneficios. La información personal que se proporcione puede utilizarse para propósitos secundarios (Ley de Privacidad, s (1)(m), Estatutos de Wisconsin]. Departamento de Desarrollo de la Fuerza Laboral División de Compensación de Trabajadores 201 E. Washington Ave., Rm. C100 P.O. Box 7901 Madison, WI Teléfono: (608) Fax: (608) DWDDWC@dwd.wisconsin.gov Según la ley, todos los proveedores de atención médica deben proporcionarle a todo empleado, empleador, asegurador de compensación de trabajadores o sus representantes cualquier tipo de información razonablemente relacionada con cualquier tipo de lesión laboral que se haya alegado. Sin embargo, determinar la relación de las fichas médicas anteriores con una lesión laboral puede ser difícil y llevar tiempo. Por consiguiente, para ayudar a que se lleve a cabo la investigación de su reclamo de manera oportuna, este documento autoriza que el proveedor de atención médica divulgue información médica sin intentar determinar la medida en que se relaciona con la lesión laboral que se ha alegado en su caso. No se le requiere que firme este documento. Puede rehusarse a firmar este documento sin poner en peligro su derecho de cobrar beneficios de compensación de trabajadores. Sin embargo, al ayudar en la investigación de su reclamo, es probable que reciba beneficios con mayor rapidez que si se rehúsa a autorizar la divulgación de información médica. Nombre del Proveedor de Atención Médica Dirección de la Calle Apartado Postal Ciudad Estado Distrito Postal Nombre del Paciente (Empleado) Nombre del Empleador Número de la Seguridad Social del Paciente - - Fecha de Nacimiento del Paciente No. de Reclamo de CT El paciente cuyo nombre aparece arriba autoriza por medio del presente documento a que el proveedor de atención médica cuyo nombre aparece arriba le divulgue todas las fichas que se han marcado a continuación y que se encuentren en su posesión y tengan que ver con la salud, el tratamiento y la evaluación del paciente a: Nombre y Dirección de la Parte Autorizada a Recibir la Información Protegida o a sus representantes designados, y a que les suministre duplicados legibles y certificados de todas las fichas, escritos, informes, resultados de pruebas y rayos x que se encuentren en su posesión y contengan esa información. Esta autorización incluye todas las fichas, informes, correspondencia u otros materiales que el proveedor de atención médica autorizado tenga en su posesión, incluso si el proveedor de atención médica no generó esos materiales, y el volver a divulgar esos materiales se autoriza por medio del presente documento. Este permiso de divulgación puede utilizarse en la investigación, preparación, evaluación, y/o la audiencia del reclamo de compensación de trabajadores que se describe arriba. MARQUE UNA DE LAS SIGUIENTES OPCIONES: A. Salud Física Únicamente. Divulgue todas las fichas, correspondencia y cualquier otra información de cualquier procedencia que tenga que ver con la salud física, el tratamiento y la evaluación del paciente, incluyendo sin limitación, las hechas o provistas por cualquier médico, enfermera, quiropráctico, osteópata, dentista, terapeuta físico, hospital, o cualquier otro proveedor de atención médica. Este consentimiento constituye la renuncia de cualquier privilegio creado por estatutos, normas, reglas o cualquier otro tipo de autoridad estatal o federal, incluyendo sin limitación el Estat. de Wis y , y 45 C.F.R B. Salud Física y de Otras Clases. Divulgue todas las fichas, correspondencia y cualquier otra información de cualquier procedencia que tenga que ver con la salud física y mental, el abuso de drogas y alcohol, las pruebas de VIH y SIDA, el tratamiento y la evaluación del paciente, incluyendo sin limitación, las hechas o provistas por cualquier médico, psiquiatra, psicólogo, enfermera, quiropráctico, osteópata, dentista, terapeuta físico, hospital, o cualquier otro proveedor de atención médica. Este consentimiento constituye la renuncia de cualquier privilegio creado por estatutos, normas, reglas o cualquier otro tipo de autoridad estatal o federal, incluyendo sin limitación el Estat. de Wis , , y , 42 C.F.R., Cap. 1, subparte C, 2.31 y 45 C.F.R Firma del Paciente (o Persona Autorizada para Firmar de Parte del Paciente) para la Opción B: Firma del Paciente (o Persona Autorizada para Firmar de Parte del Paciente) Fecha WKC-9488-E-S (N.03/2009)

9 Al firmar este impreso de consentimiento, reconozco y entiendo que: Estoy autorizando la divulgación de las fichas y la información enumeradas anteriormente. Renuncio cualquier privilegio que pueda haber evitado la divulgación de las fichas y la información enumeradas anteriormente. Entiendo que el proveedor de atención médica cuyo nombre aparece arriba, al que estoy autorizando a divulgar mi información médica protegida, no puede imponer la condición de que firme esta autorización para proporcionarme tratamiento, pago, inscripción o elegibilidad de beneficios (si es pertinente), excepto: (1) si mi tratamiento se relaciona con la investigación, o (2) los servicios de atención médica se me proporcionan únicamente con el propósito de crear información médica protegida para su divulgación a un tercero. Puedo revocar esta autorización en cualquier momento por medio de una solicitud escrita enviada a la parte autorizada arriba a recibir información, excepto que la parte autorizada arriba a recibir esa información puede contar con la información médica personal que haya recibido antes de la revocación de esta autorización. Puedo obtener copia de las fichas e información divulgadas previa solicitud escrita enviada a la parte autorizada arriba a recibir información sin costo alguno para mí. Mi información médica personal divulgada de acuerdo con esta autorización puede volver a divulgarse y puede que deje de estar protegida por la ley federal. Mi información médica personal puede divulgarse a cualquiera de los siguientes: el empleador, el asegurador de compensación de trabajadores, el Departamento de Desarrollo de la Fuerza Laboral, otras partes relacionadas con este asunto o sus abogados; la Comisión de Revisión Laboral e Industrial; cualquier tribunal o cualquier acción o proceso legal relacionados con este asunto; expertos contratados o consultados por cualquiera de las partes; y cualquiera de sus agentes, empleados, o representantes. Específicamente autorizo y consiento a cualquier tipo de divulgación y redivulgación de ese tipo. Tengo derecho a una copia de este impreso de consentimiento después de firmarlo. Si tiene preguntas acerca de este documento, debe ponerse en contacto con la División de Compensación de Trabajadores llamando al (608) No firme este documento si el nombre del proveedor de atención médica está en blanco. Este consentimiento está sujeto a revocación en cualquier momento. Si no se revoca, este consentimiento tiene efectividad por un periodo de dos (2) años a partir de la fecha de firma. Esta autorización renuncia expresamente cualquier requisito de que deba utilizarse antes de que pase un determinado número de días después de la fecha de firma, o de que deba ponerse la fecha dentro de un cierto periodo de tiempo antes de la fecha en que se utilice. Esta autorización aplicará también a las fichas de tratamiento que pueda proporcionarse en el futuro, después de la fecha de firma de esta autorización, siempre que ese tratamiento ocurra mientras esta autorización tenga todavía vigencia. Una copia fotocopiada será tan válida como el original. Firma del Paciente (o Persona Autorizada para Firmar de Parte del Paciente): Fecha: Si no está firmada por el paciente, la autoridad/designación de firmar se basa en que el paciente es: Menor de edad Incompetente Incapacitado Fallecido Otro:

10 WORKERS COMPENSATION MANAGED CARE PROGRAMS Tower Group Companies strives to deliver the highest quality and value of workers compensation products and services to our customers. We are committed to providing excellent customer service and products which will meet our customers needs in managing their workers compensation claims. Tower Group Companies participates in several Managed Care Initiatives through a Partnership with Coventry Workers Comp Services. These initiatives help to reduce workers compensation medical related expenses with a focus of timely return to work for your injured worker. A summary of each program is outlined below. Medical Bill Review Services The Medical Bill Review Services Program provides an opportunity to reduce your medical costs. The program helps to obtain the maximum savings available on every bill by processing each bill through an extensive database of state fee schedules, usual and customary charge reviews, diagnostic related group reviews, and national Preferred Provider Organizations (PPO) Network discounts. Additional savings are obtained by hospital bill auditing and out of network negotiation programs. Network Providers - Coventry Workers Comp Services provides one of the largest national workers compensation discount networks in the industry. It is comprised of the First Health, FOCUS, MetraComp, and Aetna networks; as well as other top regional PPO s. The combination of these network providers offers coverage in every jurisdiction in the country resulting in superior network savings and increased medical provider availability. These networks are comprised of medical providers specializing in occupational medicine and services focusing on quality of care and expedited return to work for the injured employee. Coventry credentials each provider within the network to provide quality medical service and who is dedicated to returning the injured employee to work. In some states, such as California and Texas state regulations allow specialty networks which provide you as an employer more control over your workers compensation medical and disability costs. The physicians within these networks are educated in evidence based treatment protocols assisting the injured employee in reaching early Maximum Medical Improvement (MMI) in accordance with medical industry guidelines. Other benefits include reduction in over utilization of medical services and excessive treatment costs with the focus in early return to work, thereby reducing your workers compensation indemnity payments. One of the first steps in providing quality medical care to your injured employee is to understand how to access network providers, and generate workplace provider panel cards or provider listings. There are two convenient ways to locate a network provider or develop provider network listings: 1. Telephonically: Simply call Coventry at x Provide the Coventry representative your employer information, the specific provider specialty you need and your geographic area (city, state and zip code). The Coventry representative will provide verbally provide you with a list of providers meeting your requirements or an electronic provider directory can be forward to you via Internet Access: For the standard national workers compensation network go to and select the Coventry Integrated Network to search for providers in your geographic network. You will be able to generate provider directories as well as determine whether a specialty physician is a member of the Network.

11 If you participate in a Specialty Network, such as a MPN or HCN, select the applicable network from the drop-down box. For California, chose the First Health Select CA MPN; Texas participants in the Coventry HCN. For large panel card production or if you require additional information regarding web access please contact Tower Group Medical Management division at Medical Case Management - Coventry Workers Comp Services provides you with a variety of programs to help manage the care of your injured employees, including medical case management, catastrophic case management, vocational case management, utilization reviews (URAC certified), return-to-work programs, and independent medical examinations. All of these programs are dedicated to advocating appropriate, highquality medical treatment, facilitating prompt return to work and effectively managing your claim costs. Experienced medical professionals work with treating physicians and your claims adjuster as advocate for the injured employee s medical care. These professionals ensure that your employee receives the most appropriate and timely care. Facilitating effective communication between medical providers and claims adjusters also provides a quicker resolution of your claims. Tower s dedicated team of adjusters will facilitate the integration of these products and services to assist in reducing injured employee s lost time and medical costs. Your Tower Group designated adjuster will be responsible for managing all aspects of the injured employee s claim and facilitating open lines of communication between all parties to resolve any outstanding issues or concerns. Please feel free to contact your claims adjuster, or Tower Group Managed Care Services, if you have any questions regarding these programs.

12 Re: Important Information about your Workers Compensation Prescriptions This letter is provided to inform you that your employer s workers compensation, Tower Group Companies, has selected PMSI as its workers compensation pharmacy partner.with PMSI, you can choose to pick-up your medications for your work-related injury at a nearby pharmacy through a program known as Tmesys, or have them delivered to your home through the mail. Within the next few weeks, you will receive a new workers compensation pharmacy card in the mail. You should give the Tmesys card to the pharmacist at a participating pharmacy of your choice with your next refill or new prescription for your work-related injury. If you do not receive your new pharmacy card within two weeks, please call Tmesys at and we will be happy to assist you or send another card. If you are interested in finding out about how to receive your prescriptions through the mail, please call To help you transition to the new pharmacy program, we have provided answers to some frequently asked questions: Q: How do I know if my pharmacy participates with the new program? A: You can find out if your normal preferred pharmacy is part of the Tmesys network by referring to the Pharmacy Center on our website, Click on Pharmacy Locator and select how you would like to search for a nearby pharmacy. You may also call the helpdesk at to find a network pharmacy near you. Q: How does this affect my workers compensation claim? A: Using PMSI s program for your workers compensation medications will enable you to continue to receive your prescriptions for your work-related injury. You may choose to visit your local pharmacy, as long as the pharmacy is one of the more than 60,000 pharmacies in the Tmesys network, or you can have your prescriptions delivered to your home through our convenient mail order program. Q: Who do I call with questions about the program? A: PMSI has representatives available to help you with any questions that you may have about the pharmacy program. Please call our help desk at to speak to a representative. If you have any questions about your workers compensation claim, we will help you reach your claims adjuster for assistance. We look forward to serving you and meeting your workers compensation medication needs. Sincerely, PMSI Necesitas ayuda en español? Llame al

13 First Fill Temporary Pharmacy Card Making it easy to get your workers compensation prescriptions filled. Employer: 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. Questions? Call Necesitas ayuda en español? Llame al Prescription Card CARRIER / TPA INJURED WORKER NAME SOCIAL SECURITY NUMBER EMPLOYER DATE OF INJURY 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 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 NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # Pharmacist: 1. Call the Tmesys Pharmacy Help Desk at Provide the information from the card. 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 your local Walgreens or Rite Aid Pharmacy Call us: Use our pharmacy locator online: PMSI, Inc. All rights reserved. C

14 First Fill Temporary Pharmacy Card En Primer Relleno Tarjeta Temporal de Farmacia Hacerlo fácil de llenar sus recetas de la compensación del trabajador. Employer: Immediately upon receiving notice of injury, fill in the information below and give it to your employee. Empleado Lesionado: 1. Si usted necesita una receta para un accidente de trabajo o enfermedad ocupacional, ir a una farmacia de la red Tmesys. 2. Dar esta página al farmacéutico. 3. El farmacéutico surtir su receta sin costo alguno. Preguntas? Llame al Need help in English? Call Prescription Card PORTADORA NOMBRE DEL TRABAJADOR LESIONADO NUMERO DE SEGURO SOCIAL EMPLEADOR FECHA DE LA LESIÓN 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 Aviso a los titular de la tarjeta: Esta tarjeta debe ser presentada a su farmacia para recibir medicamento para tratar su lesión relacionada con el trabajo.sólo es válido dentro de los 30 días de su fecha de la lesión. Para obtener información acerca del programa o para encontrar farmacias cercanas llame NDC Envoy RxBin or RxPCN CAL or Envoy Acct. # (Para crear una tarjeta para su billetera, corte a lo largo de la linea exterior y doblar por la mitad.) 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. Encontrar una farmacia de la red Utilice uno de estos métodos fáciles para encontrar una farmacia de la red: Visite a su local de Walgreens y Rite Aid Pharmacy. Nos llame al: Utilice nuestro localizador de farmacias en linea: PMSI, Inc. Todos los derechos reservados. C

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