Reporting an Accident/Injury



Download 161,44 Kb.
Sana28.06.2017
Hajmi161,44 Kb.
#18699
Reporting an Accident/Injuryl:\sepd_logo_2015.jpg

  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

(321) 633-8620


Store 127 (Waldo)

CareSpot Express Healthcare

720 SW 2nd Ave Ste 160A

Gainesville, FL 32601

(352) 240-8000


Store 12 (Yeehaw Junction)

Urgent Care West

2050 40th Ave Ste 6

Vero Beach, FL 32960

(772) 564-0175


Best Western Hotel & Store 24 (Titusville)

Medfast Urgent Care Centers LLC

5005 Port St John Pkwy

Cocoa, FL 32927

(321) 633-8620


Store 392 (Fernandina Beach)

Amelia Urgent Care LLC

96279 Brady Point Rd

Fernandina Beach, FL 32034

(904) 321-0088


Store 50 and 52DQ (Fellsmere)

Indian River Health Services Inc

801 Wellness Way Ste 107

Sebastian, FL 32958

(772) 226-4200


Store 11 and 91DQ (Saint Augustine)

Healing Arts Urgent Care

120 Health Park Blvd Ste 1

Saint Augustine, FL 32086

(904) 823-3401


Store 350 (Orlando)

Florida Hospital Central Care

12500 S Apopka Vineland Rd

Orlando, FL 32821

(407) 934-2273


Store 57 (Flagler Beach)

Florida Hospital Central Care

1270 Palm Coast Pkwy NW

Palm Coast, FL 32137

(386) 225-4631


Store 296 (Davenport)

Legends Family Medical Center

1485 Legends Blvd

Champions Gate, FL 33896

(407) 390-6480


Store 401 (Winter Haven)

First Help Urgent Care Clinic

320 1st St S

Winter Haven, FL 33880

(863) 299-8485


Store 345 (Sanford)

Florida Hospital Central Care

4451 W. State Road 46

Sanford, FL 32771

(407) 330-3412



First Report of Accident/Injuryl:\sepd_logo_2015.jpg

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/Injuryl:\sepd_logo_2015.jpg
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 Physicianl:\sepd_logo_2015.jpg

AmeriSys/Coventry Network

Date:      

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

Employer Telephone Number: (321) 631-0245, 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: 407-352-5788
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

Download 161,44 Kb.

Do'stlaringiz bilan baham:




Ma'lumotlar bazasi mualliflik huquqi bilan himoyalangan ©hozir.org 2024
ma'muriyatiga murojaat qiling

kiriting | ro'yxatdan o'tish
    Bosh sahifa
юртда тантана
Боғда битган
Бугун юртда
Эшитганлар жилманглар
Эшитмадим деманглар
битган бодомлар
Yangiariq tumani
qitish marakazi
Raqamli texnologiyalar
ilishida muhokamadan
tasdiqqa tavsiya
tavsiya etilgan
iqtisodiyot kafedrasi
steiermarkischen landesregierung
asarlaringizni yuboring
o'zingizning asarlaringizni
Iltimos faqat
faqat o'zingizning
steierm rkischen
landesregierung fachabteilung
rkischen landesregierung
hamshira loyihasi
loyihasi mavsum
faolyatining oqibatlari
asosiy adabiyotlar
fakulteti ahborot
ahborot havfsizligi
havfsizligi kafedrasi
fanidan bo’yicha
fakulteti iqtisodiyot
boshqaruv fakulteti
chiqarishda boshqaruv
ishlab chiqarishda
iqtisodiyot fakultet
multiservis tarmoqlari
fanidan asosiy
Uzbek fanidan
mavzulari potok
asosidagi multiservis
'aliyyil a'ziym
billahil 'aliyyil
illaa billahil
quvvata illaa
falah' deganida
Kompyuter savodxonligi
bo’yicha mustaqil
'alal falah'
Hayya 'alal
'alas soloh
Hayya 'alas
mavsum boyicha


yuklab olish