Reporting an Accident/Injury

Reporting an Accident/Injury

1. 
   Accident/Injury Occurs
   
2. 
   Employee Reports Accident/Injury to Supervisor/HR
   
   1. 
      If Accident/Injury is life threatening, Supervisor calls 911 or sends employee to the nearest hospital.
      
   2. 
      If Accident/Injury requires immediate medical attention (not life threatening) and request medical treatment, Supervisor sends employee to the applicable urgent care clinic below.
      
   3. 
      If employee is sent for medical treatment, Supervisor supplies employee with the Introductory Letter to Physician.
      
      1. 
         Letter includes instructions on post-accident drug screening. This must be done within 24 hours of an accident/injury.
         
   4. 
      If employee declines medical treatment, supervisor makes sure that this is indicated on the paperwork.
      
3. 
   Supervisor Collects the following paperwork and sends to HR
   
   1. 
      First Report of Injury – Completed by Supervisor/Employee
      
   2. 
      Supervisor’s Report of Injury – Completed by Supervisor
      
   3. 
      Employee’s Report of Injury – Completed by Employee
      
   4. 
      Provide any witness statements
      
4. 
   HR files claim with Worker’s Compensation Insurance Carrier.
   
5. 
   W/C Insurance company will continue to stay in touch with HR and Injured Employee
   

Office/Store, 83, & 134 (Cocoa) Medfast Urgent Care Centers LLC 5005 Port St John Pkwy Cocoa, FL 32927 [phone]	Store 127 (Waldo) CareSpot Express Healthcare 720 SW 2^nd Ave Ste 160A Gainesville, FL 32601 [phone]	Store 12 (Yeehaw Junction) Urgent Care West 2050 40^th Ave Ste 6 Vero Beach, FL 32960 [phone]
Best Western Hotel & Store 24 (Titusville) Medfast Urgent Care Centers LLC 5005 Port St John Pkwy Cocoa, FL 32927 [phone]	Store 392 (Fernandina Beach) Amelia Urgent Care LLC 96279 Brady Point Rd Fernandina Beach, FL 32034 [phone]	Store 50 and 52DQ (Fellsmere) Indian River Health Services Inc 801 Wellness Way Ste 107 Sebastian, FL 32958 [phone]
Store 11 and 91DQ (Saint Augustine) Healing Arts Urgent Care 120 Health Park Blvd Ste 1 Saint Augustine, FL 32086 [phone]	Store 350 (Orlando) Florida Hospital Central Care 12500 S Apopka Vineland Rd Orlando, FL 32821 [phone]	Store 57 (Flagler Beach) Florida Hospital Central Care 1270 Palm Coast Pkwy NW Palm Coast, FL 32137 [phone]
Store 296 (Davenport) Legends Family Medical Center 1485 Legends Blvd Champions Gate, FL 33896 [phone]	Store 401 (Winter Haven) First Help Urgent Care Clinic 320 1^st St S Winter Haven, FL 33880 [phone]	Store 345 (Sanford) Florida Hospital Central Care 4451 W. State Road 46 Sanford, FL 32771 [phone]

First Report of Accident/Injury

Supervisor's Report of Accident/Injury

Employer M&R Enterprises of Brevard				Injured Employee’s Name      				Injury Date      
Location of Accident      		Injury Time        am  pm				Shift Start Time        am  pm
Manager/Supervisor      		Employee’s Job Title      
Rate of Pay        hr  wk	Number of hours work per day      				Number of days work per week      
Where and how did the accident happen?      
What were you doing at the time of the accident?      
Specify equipment, substance or object connected with accident?      
Nature of Injury (Scratch, cut, bruise, etc.)      
Part of Body Injured (Left Ring Finger, Right Ankle, etc.)      
Were there any witnesses? (See attached witness statements)  Yes  No; If yes, Names:      
Employee was Referred to:      
Accident Resulted In:  Injury  Illness  Property Damage  Near Miss  First Aid  Medical Clinic Treatment  Lost Time  No Injury/Illness
Employee was Referred to:       
Measures recommended to prevent a similar accident:      
Did Employee Return to Work?  Yes  No			Date Returned to Work:      				Time Returned to Work:        am  pm
Supervisor/Manager Signature:						Date:

First Report of Accident/Injury
Employee's Report of Accident/Injury

Employer M&R Enterprises of Brevard					Injured Employee’s Name      					Injury Date      
Location of Accident      			Injury Time        am  pm				Shift Start Time        am  pm
Hire Date      	Requesting Medical Treatment?  Yes  No						Job Title      
Employee Address      						City      	State   		Zip      
Date of Birth      		SSN      					Gender  Male  Female
Where and how did the accident happen?      
What were you doing at the time of the accident?      
Specify equipment, substance or object connected with accident?      
Nature of Injury (Scratch, cut, bruise, etc.)      
Part of Body Injured (Left Ring Finger, Right Ankle, etc.)      
Were there any witnesses? (See attached witness statements)  Yes  No; If yes, Names:      
Employee was Referred to:       
Did you return to work?  Yes  No				Date Returned to Work:      				Time Returned to Work:        am  pm
Accident Resulted In:  Injury  Illness  Property Damage  Near Miss  First Aid  Medical Clinic Treatment  Lost Time  No Injury/Illness
Employee Signature:							Date:

Introductory Letter to Physician

AmeriSys/Coventry Network

Date:      

Employer Name: M&R Enterprises of Brevard, Inc.

Employer Telephone Number: [phone], extension 116

Dear Dr.     :

Employee Name is scheduled for an initial visit as an employee of M&R Enterprises of Brevard, Inc. which is a participant in the FHM Insurance Company/AmeriSys/Coventry Network. This letter does not confirm that the injury or condition is covered by Worker’s Compensation Insurance. That determination will be made as soon as an investigation is completed by our claims administrator, USIS.
DRUG TESTING IS REQUIRED:  Urinalysis

 Breathalyzer (blood test if necessary)

We are working closely with AmeriSys/Coventry Network and the involved medical providers to ensure that our employees receive access to timely and medically necessary treatment for their industrial injuries. In the best interest of our employees, we will have modified work available, which would allow the employee to return to work at the earliest possible date. Please keep this in mind as you treat this employee.
PLEASE CONACT UTILIZATION MANAGEMENT

AT 888-346-3461 Ext. 3131

WHEN ONE OF THE FOLLOWING OCCURS:

1. 
   New Injury with Disability > 7 Days & No Release to Return to Work
   
2. 
   Hospitalization
   
3. 
   Anticipated Surgery
   
4. 
   Physical Therapy or Chiropractic Treatment Recommended
   
5. 
   Referral to Provider
   
6. 
   Assistance Required to Return Injured Employee to Work
   
7. 
   Repeat Major Diagnostic Studies
   

All claims for treatment must be submitted to the address below on an HCFA 1500, UB 92 or the appropriate form required by the state. Please submit all medical reports within the time frame required by the applicable state law.
FHM Insurance Company

P.O. Box 616648, Orlando, FL 32861-6648

407-351-1212/888-346-3461- Ext 6353; FAX: [phone]
Should you have any questions regarding your participation in the Coventry Network, please call 800-342-5888 or 800-937-6824.

Sincerely,

Chrissy Council, HR Manager

Updated: 5/10/2017