Fillable ENCOVA INSURANCE INJURY KIT (Washington & Jefferson College)

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ENCOVA INSURANCE INJURY KIT (Washington & Jefferson College)

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  • 122 check-boxes
  • 311 other fields

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File type: PDF

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POLICY #
COMPANY NAME
CONTACT PERSON AND NUMBER
JURISDICTION
encova.com
WC-5134 12-19
ENCOVA
INSURANCE
INJURY KIT
PENNSYLVANIA
Secure proper medical care for your employee and inform them if
modified/light duty work is available.
Follow your company’s procedure to report the injury. If you are not aware
of the procedure, call your supervisor.
Give this envelope to your employee and ensure they complete the
enclosed forms.
Report the injury to Encova within 24 hours using one of the
following methods:
• Internet: File electronically through StreetConnect; contact your agent
or Encova’s Customer Service Unit for information about becoming a
StreetConnect user
• Phone: Call 866-452-7425, select “policyholder” and option 1
(This is the quickest and most convenient option)
• Email: Send an email with the completed First Report of Injury as an
attachment to claimsintake@encova.com; visit the specific jurisdiction’s
website to obtain the First Report of Injury form
• Fax: Send the completed First Report of Injury to 877-293-5513 or
304-941-1151; visit the specific jurisdiction’s website to obtain the First
Report of Injury form
If you have a StreetConnect account, you can click the Virtual Claims Kit link,
choose the appropriate carrier and jurisdiction and locate the correct form.
ENCOVA INJURY KIT
SUPERVISOR CHECKLIST
encova.com
INJURED EMPLOYEE
CHECKLIST
Report all injuries to supervisor
(Alabama, Georgia, Indiana, Iowa, Kansas, Missouri, North Carolina, Pennsylvania, South Carolina,
Tennessee and Virginia allow your employer to either choose your physician or provide you with a list
of approved physicians)
Obtain either a full-duty release or a completed Physician Statement of Physical
Capabilities Form from the doctor (if released for light/modified duty)
If released to return to work, return on your next scheduled work day with either
your full-duty release or the Physician Statement of Physical Capabilities Form
If not released to return to work, you must call your supervisor within one
business day and provide:
• Physician’s name, address and phone number
• Date of your next scheduled doctor appointment
Return Incident Report to your supervisor upon return or within 24 hours
encova.com
Employer:
Immediately upon receiving notice of injury, fill in the information
above and give this form to the employee.
Injured Employee:
If you need a prescription filled for a work-related injury or
illness, go to an Optum Tmesys
®
network pharmacy. Give this
temporary card to the pharmacist. The pharmacist will fill
your prescription at low or no cost to you.
If your workers’ compensation claim is accepted, you will
receive a more permanent pharmacy card in the mail.
Please use that card for other work-related injury or illness
prescriptions.
Most pharmacies and all major chains are included in the
network. To find a network pharmacy call 1-866-599-5426
or visit tmesys.com.
NOTE: This First Fill card is only valid for your workers’ compensation injury or illness.
MAKING IT EASY ...
TO GET WORKERS’ COMPENSATION PRESCRIPTIONS FILLED.
Optum has been chosen to manage your workers’ compensation pharmacy benefits for your employer or their insurer.
Below is your First Fill card that will allow you to receive your injury-related prescriptions at your local pharmacy. Please
fill out the card based on the instructions below.
1-866-599-5426
Questions? Need Help?
IMP14-1913-23
WORKERS’ COMPENSATION PRESCRIPTION DRUG PROGRAM
Notice to Cardholder: Present this card to the pharmacy to receive medication for
your work-related injury. To locate a pharmacy: tmesys.com.
CARRIER/TPA EMPLOYER
INJURED WORKER NAME
SOCIAL SECURITY NUMBER DATE OF INJURY (YYMMDD)
Please provide directly to Pharmacist
Encova Insurance
(formerly Brickstreet Insurance)
Attention Pharmacists: Enter RxBIN, RxPCN and GROUP. Member ID # format is
the date of injury and SSN combined as follows: YYMMDD123456789.
Tmesys is the designated PBM for this patient.
Tmesys Pharmacy Help Desk
1-800-964-2531
NDC Envoy
RxBIN 004261 or
or
002538
RxPCN
GROUP
CAL
BRIKFF
Envoy Acct. #
The following entities comprise the Optum Workers Compensation and Auto No Fault division: PMSI, LLC, dba Optum Workers Compensation
Services of Florida; Progressive Medical, LLC, dba Optum Workers Compensation Services of Ohio; Cypress Care, Inc. dba Optum Workers Com-
pensation Services of Georgia; Healthcare Solutions, Inc., dba Optum Healthcare Solutions of Georgia; Settlement Solutions, LLC, dba Optum
Settlement Solutions; Procura Management, Inc., dba Optum Managed Care Services; Modern Medical, dba Optum Workers Compensation
Medical Services, collectively and individually referred as “Optum.”
Optum
PO Box 152539
T
ampa, FL 33684-2539
MEDICAL RECORDS RELEASE
TO: Any licensed physician, chiropractor, medical practitioner, hospital, clinic or other medical or medically
related facility, insurance company or other organization, institution or person that has any records or
knowledge of my health, history, condition or well-being
In accordance with the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) and other
applicable federal and state privacy laws and regulations, I, __________________, __________________
hereby authorize the use or disclosure of my individually identifiable health information described
below to __________________, P.O. Box 3151 Charleston, WV 25322.
For purposes of this Authorization, individually identifiable health information shall mean: Any and all of
my personal health information created, received or obtained, including any medical or dental records,
X-ray or radiology films, pathology materials, MedFlight reports, insurance-related documents and benefit
forms or any other medically related record or item that relates to my physical health or condition, the
provision of health care to me, or the payment for my care, as the foregoing information relates to the
assessment, treatment or recordation of history related to any injury to me or any disease that affects me
regardless of the time or cause of the onset of said injury or disease.
I understand that the information in my health record may include information relating to sexually
transmitted disease, acquired immunodeficiency syndrome (AIDS), AIDS related complex (ARC), or
human immunodeficiency virus (HIV). It may also include information about behavioral or mental health
services, treatment for alcohol and drug abuse, psychological or psychiatric treatment, social services
counseling, communicable diseases or infections, tuberculosis and hepatitis. Such records will be released
through this authorization unless otherwise indicated. Do not release any of the following information if
an “x” appears before the description.
I further authorize Recipient to use, disclose or re-disclose any and all of my above-described health
information and to make copies thereof for purposes of evaluating and administrating an insurance claim
I have filed with Recipient. I understand that my health information may be re-disclosed by Recipient and
may then no longer be protected by any applicable federal or state privacy laws or regulations.
I understand that I may revoke this authorization at any time by sending a written notice of revocation
to Recipient at the address listed above. I understand that my revocation will only be effective after it is
received by Recipient and that the revocation will not apply to information that has already been released
in response to this authorization.
This authorization shall expire on:
. If no date is specified, this authorization shall expire one
year from the date it is signed. Any disclosures made prior to my revocation or prior to the expiration of
this authorization will not be affected by my revocation or by the expiration of this authorization.
I understand and agree that a photocopy or electronically reproduced copy of the original of this
authorization shall have the same effect as an original.
Signature of individual Date
Social Security number Date of birth
Signature of personal representative, estate representative or guardian
(Provide documentation of authority to act for individual)
MEDR 11-19
Claimant name Claim number
Company name
Behavioral healthHIV/AIDS Drug and alcohol Genetic history
Encova
click to sign
signature
click to edit
click to sign
signature
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1
(Compatible with StreetConnect claim filing and OSHA Form 301 filing)
Please note: The fields highlighted in grey are pre-populated in the online system.* Denotes required field
Date of injury: * Policy number: Policy name: Case # from OSHA Log
(if applicable):
Filing date:
Claim type: *
Incident
Indemnity
Medical only
Jurisdiction:
POLICY / DEMOGRAPHIC QUESTIONS
What is your name? * What is your job title?
What is your telephone
number? *
What is your fax number? What is your email address?
Are you the contact for this claim?
No
Yes
If no, who should we contact for additional information?
What is the contact’s phone number? What is the contact’s email?
Is this a Federal Longshore (USL&H) claim?
No
Yes Are you reporting a fatality?
No
Yes
Date of death: *
Date of injury/date of last exposure: * What is your policy number? *
What is the employee’s
ID type? *
Employment Visa number
Green Card number
Passport number
Social Security number
ID number: *
What is the employee’s name? First: * MI: Last: * Sux:
What is the employee’s mailing address? Street/P.O. Box: *
Zip: * City: * State: * Country:
What is the employee’s physical address? Street/P.O. Box:
Zip: City: State: Country:
What is the employee’s primary telephone number? What is the employee’s alternate telephone number?
What is the employee’s regular work schedule?
DEMOGRAPHIC / WAGE QUESTIONS
What is the employee’s date of birth? *
Gender: *
Male
Female
Unknown
Marital status: *
Married
Single
Divorced
Widowed
Separated
Common law
Unknown
What is the industrial code? * What is the job title? *
Description of employee’s job and regular duties:
CLAIM FILING FORM
2
DEMOGRAPHIC / WAGE QUESTIONS
What is the employee’s hire date? * What is the state of hire for this employee?
Employment type:
Full-Time
Part-Time
Volunteer
Is the employee: An ocer?
No
Yes
An owner/part owner?
No
Yes
What is the hourly rate of pay for this employee? What are the number of hours worked per week for
this employee?
What is the daily rate of pay for this
employee?
How many hours per day did the employee
work?
How many days per week did the
employee work?
Is there any additional wage information not included in the daily rate (i.e. commissions, etc.)?
Is the employee continuing to receive full wages?
No
Yes
INJURY QUESTIONS
What is the primary work location? *
Name:
Address: * Country:
Zip: * City: * State: *
What is the reporting location?
Did the accident occur on the employer’s property? *
No
Yes
If no, where did the accident occur? *
Name: *
Address:
Zip: City: State: Country:
Was this the employee’s regular department?
No
Yes
In what department did the accident occur?
Was injury the result of a motor vehicle accident?
No
Yes
Was any equipment involved in the injury?
No
Yes
If yes, what equipment?
What was the employee doing just before the incident occurred?
How did the accident occur? *
What object or substance directly harmed the employee?
Was safety equipment provided?
No
Yes Was safety equipment used?
No
Yes
If yes, what type?
What was the injured body part(s)? *
What is the body part location? *
Bilateral
Left
Lower
Middle
Right
Upper
Not applicable
What is the nature of the injury (sprain, strain, etc.)? *
What was the cause of injury? *
Are you aware of a previous injury to this body part? *
No
Yes
If yes, please explain: *
Do you have knowledge of pre-existing disability, industrial or non-industrial?
No
Yes
If yes, please explain: *
Are there outside activities or medical conditions that would aect this injury?
No
Yes
If yes, please explain: *
3
INJURY QUESTIONS
List all others involved in the accident with contact information:
1.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
2.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
3.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
List all witnesses to the accident (or enter “none”):
1.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
2.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
3.
First name: MI: Last name:
Address:
Zip: City: State: Country:
Phone:
4
RETURN-TO-WORK QUESTIONS
What time did the employee begin work? * (Include a.m. or p.m.)
What time did the accident occur? * (Include a.m. or p.m.) Who was notified of the accident?
When did the injured worker notify the employer? * (Date)
Did the claimant stop work?
No
Yes
What is the loss type?
Incident only
Indemnity
Medical only
Modified duty with no wage loss
Modified duty with wage loss
What was the last date worked? What time did the employee stop work?
(Include a.m. or p.m.)
Has the employee returned to work?
No
Yes
Date of return to work?
Did/will the claimant return to full duty?
No
Yes Do you have transitional/modified work available?
No
Yes
Number of hours per week? Modified daily rate of pay?
MEDICAL QUESTIONS
Was medical treatment provided?
No
Yes
Name of medical provider:
Medical facility/provider’s address:
Zip: City: State: Country:
Was employee treated in an emergency room?
No
Yes
Was employee hospitalized overnight as an in-patient?
No
Yes
What was the method of transportation?
Helicopter
Ambulance
Personal vehicle
Other
Do you require your employees to be drug tested?
No
Yes
If yes, when was the employee last tested?
Was an incident report completed? *
No
Yes Do you have any reason to question this injury? *
No
Yes
Do you have any comments for the record?
PHYSICIAN STATEMENT
OF PHYSICAL ABILITIES
Return completed form to:
Encova Insurance
P.O. Box 3151
Charleston, WV 25332-3151
Or fax to: 877-898-6980
Please complete this form after your examination of the patient. Indicate the patient’s capabilities, including work hours, duties, environmental factors
and any other information pertinent to this employee’s recovery and early return to work.
Please indicate the extent to which the employee can perform the following:
(C - Constantly = greater than 67% F - Frequently = 34% to 66% O - Occasionally = 6% to 33% R - Rarely = Less than 5% N - Never = 0%)
Claimant name: Claimant number: Date of injury:
Physician name: Physician telephone:
Date released with above restrictions: Date released for full-duty work:
Projected date for MMI: Date and time of next appointment:
Physician signature: Date:
Medical diagnosis:
Please indicate the extent to which the employee can perform the following work postures and work activities
during the usual workday.
Standing
Constantly
Frequently
Occasionally
Rarely
Never
Sitting
Constantly
Frequently
Occasionally
Rarely
Never
Walking
Constantly
Frequently
Occasionally
Rarely
Never
Climbing
Constantly
Frequently
Occasionally
Rarely
Never
Kneeling
Constantly
Frequently
Occasionally
Rarely
Never
>67% of workday 34% - 66% of workday 6% - 33% of workday <5% of workday 0% of workday
11-19
Lifting/carrying C F O R N Pushing/pulling C F O R N
5 lbs. or less 5 lbs. or less
5–10 lbs. 5–10 lbs.
11-20 lbs. 11–20 lbs.
21–40 lbs. 21–40 lbs.
41–60 lbs. 41–60 lbs.
61–100 lbs. 61-100 lbs.
100+ lbs. 100+ lbs.
Activity Driving
Bend Automatic drive
Squat Standard drive
Twist/turn
Upper extremities Yes No
Crawl Simple grasping
Right
Left
Right
Left
Reach above
shoulder
Pushing/pulling
Right
Left
Right
Left
Type/keyboard
Operate foot controls
Yes No
Joystick/
hand controls
Right
Left
Right
Left
Vibration Simultaneous
Yes
No
Comments:
encova.com
EMPLOYEE’S RIGHTS & DUTIES UNDER SECTION 306 (F.1) OF THE PENNSYLVANIA WORKERS’
COMPENSATION ACT
If you are injured while at work and medical treatment is necessary, you are required to visit one of the physicians or health care
providers on the list designated by your employer for a period of 90 days from your first visit with the physician or health care provider.
All reasonable medical treatment and supplies (e.g. medicines, prosthetics) related to the injury will be paid for by the employer
provided treatment is by a designated physician or health care provider on the list during the 90-day period. Charges for treatment and
supplies are specified by the ACT. You are not responsible for the payment of any charges in excess of those specified by the ACT.
During the 90-day period, you may change from one designated physician or health care provider on the list to another physician or
health care provider on the list, and the treatment will be paid for by the employer.
If the designated physician or health care provider refers you to a non-designated provider, the employer will pay for the treatment by
the non-designated provider.
You have the right to obtain emergency medical treatment from a non-designated physician or health care provider however, the
subsequent non-emergency treatment must be by a designated physician or health care provider for the remainder of the 90-day period.
You may seek treatment or consultation from a non-designated physician or health care provider during the 90-day period however, you
are responsible for the charges for this treatment during the 90-day period.
If the employer-designated physician or health care provider recommends invasive surgery, you are permitted to obtain a second opinion
from a non-designated physician or health care provider. Your employer will pay for the cost for this opinion. If this opinion differs from
the opinion of the designated physician or health care provider and provides a specific and detailed course of treatment, you may elect
to undergo this treatment. The treatment however must be provided by a designated physician or health care provider for 90 days from
the date of the visit to the non-designated physician.
You have the right to seek treatment from any physician or health care provider after the 90-day period has ended, and your employer
will pay for this treatment provided it is reasonable and necessary.
You have the duty to notify your employer of treatment by a non-designated physician or health care provider within five days of
your first visit to this physician or provider. Your employer may not be required to pay for treatment by a non-designated physician
or health care provider prior to notification. The employer however shall pay for this treatment once notified unless the treatment is
found to be unreasonable.
Signing this form is an acknowledgment of your rights and duties. You may not refuse to sign this acknowledgment in order to avoid
your duties.
If you have any questions, please feel free to contact the Bureau of Workers’ Compensation at 1-800-482-2383 or 1-717-783-5421.
I ACKNOWLEDGE THAT I HAVE BEEN INFORMED OF AND UNDERSTAND THE ABOVE RIGHTS AND DUTIES.
Employee name Employee signature Date
Supervisor name Supervisor signature Date
IF THE EMPLOYEE IS UNABLE OR REFUSED TO SIGN, IT IS ACKNOWLEDGED THAT THE EMPLOYEE WAS PROVIDED A COPY OF
THIS DOCUMENT.
Supervisor name Supervisor signature Date
encova.com
NOTICE: MEDICAL TREATMENT FOR YOUR WORK INJURY OR OCCUPATIONAL ILLNESS
Your employer has selected a list of six or more physicians and other health care providers who are available to treat your work-related
injuries and illnesses during the first 90 days of treatment. This list is posted at _______________________________________________
___________________________ for you to view. Also, you may get a copy of this list from _____________________________________.
If you are injured at work or suffer an occupational illness, you have certain legal RIGHTS and DUTIES under Section 306(f.l)(1)(i) of the
Workers’ Compensation Act regarding your medical treatment. These rights and duties are summarized below.
MEDICAL TREATMENT: DURING THE FIRST 90 DAYS
• You have the RIGHT to receive reasonable and necessary
medical treatment for your work injury or occupational illness.
Your employer must pay for the treatment, as long as the
treatment is by one of the listed providers.
• You have the RIGHT to choose which of the listed providers
will treat you for your work injury or illness.
• You have the RIGHT to switch among any of the listed
providers when you receive treatment; and if a listed provider
refers you to a provider not on your employer’s list, you have
the RIGHT to receive treatment from the referral provider.
• You have the RIGHT to receive emergency medical treatment
from any provider. However, non-emergency treatment must
be given by a listed provider.
• If a listed provider prescribes surgery for you, you have the
RIGHT to receive a second opinion from any provider of your
choice. If that opinion is different from the opinion of the
listed provider, you have the RIGHT to choose which course
of treatment to follow. If you choose the treatment prescribed
in the second opinion, you must receive the treatment from a
listed provider for a period of 90 days after the date of your
visit to the provider of the second opinion.
• You have the DUTY to visit one or more of the listed providers
for the first 90 days of treatment for your work injury or
illness if you expect your employer to pay for the medical
treatment you receive.
• If you seek treatment for your work injury or illness from a
provider who is not on the list, your employer may not have
to pay for this medical treatment during this 90-day period.
Therefore, you should talk to your employer before seeking
treatment from a provider who is not on the list.
• You have the RIGHT to receive treatment from any physician
or other health care provider of your choice, whether or not
they are listed by your employer. Your employer must pay for
this treatment, as long as it is reasonable and necessary for
your work injury or occupational illness and has been properly
documented by the physician or other health care provider.
• You have the DUTY to notify your employer if you receive
treatment from a physician or other health care provider who
is not listed by your employer. You must notify your employer
within five days of the first visit to any provider who is not on
your employer’s list. The employer may not be required to pay
for treatment received until you have given this notice.
IMPORTANT: The requirements your employer must meet to have a valid list of at least six providers are shown on the reverse side of this
form. If the list does not meet these requirements, it is not a valid list, and you have the right to seek medical treatment for your work
injury or occupational illness from any health care provider of your choice.
MEDICAL TREATMENT: AFTER THE FIRST 90 DAYS
Your signature on this form indicates that you have been informed of and you understand these rights and duties.
If you have questions, be sure you have your rights and duties explained to you before signing this form.
I HAVE BEEN INFORMED OF MY MEDICAL TREATMENT RIGHTS AND DUTIES WITH REGARD TO WORK-RELATED INJURIES AND
OCCUPATIONAL ILLNESSES. THIS NOTICE WAS PRESENTED TO ME AT (check one):
TIME OF HIRE
WHEN I WAS INJURED
OTHER
EMPLOYEE: DATE:
EMPLOYER REPRESENTATIVE: DATE:
(OVER)
1. There must be at least six health care providers on the list, but there
may be more than six listed.
2. At least three of the health care providers on the list must be physicians.
3. No more than four of the health care providers on the list may be
coordinated care organizations (CCOs).
4. The names, addresses, phone numbers and areas of medical specialties
of all health care providers must be included on the list.
5. The health care providers on the list must be geographically accessible
and must have specialties that are appropriate based on the anticipated
work-related medical problems of the employees.
6. Your employer must specify on the list if any of the health care providers
on the list are employed, owned or controlled by your employer or its
workers’ compensation insurance company.
NOTE: Your employer’s list of health care providers must meet all of the
above requirements. If the list does not meet all of these requirements, you
do not have to choose a provider from the list. Instead, you have the right
to seek medical treatment with any health care provider of your choice.
BUREAU OF WORKERS’ COMPENSATION
HELPLINE INFORMATION CENTER
1-800-482-2383 (long-distance calls inside PA)
1-717-772-4447 (local and calls outside PA)
encova.com
REQUIREMENTS FOR EMPLOYER’S LIST OF HEALTH CARE PROVIDERS
encova.com
ACCIDENT
INVESTIGATION
Every accident should be investigated thoroughly to determine the cause and
put preventive measures in place. The investigation should be conducted as
soon as possible to get the most accurate information, obtain the facts and
prevent recurrence.
STEPS TO FOLLOW
1. Receive notification of incident
2. Initiate the investigation
a. Secure the scene
b. Form an investigative team (co-workers, maintenance, engineers, safety, etc.)
c. Collect the facts
d. Analyze the facts
3. Determine if reporting to authorities such as OSHA, CDC, etc. is required
4. Complete required reports
a. Employee Incident Report
b. Witness statement
c. Include pictures
d. Forward report
5. Identify
a. Root cause(s)
b. Contributing factor(s)
c. Corrective action(s)
6. Implement corrective action(s)
a. Immediate action(s)
b. Short term
c. Long term
7. Educate employee(s)
THE QUESTIONS BELOW WILL ASSIST IN DETERMINING
THE CAUSATION FACTORS OF THE ACCIDENT AND
POSSIBLE CORRECTIVE ACTIONS.
QUESTIONS
TO ASK
IF THE CAUSES APPEAR TO BE
CONDITIONS ACTIONS
WHO
was responsible for it?
can give me answers?
should take corrective action?
is best qualified to do it?
can give me answers?
can show me what was being
done?
WHAT
caused it to exist?
caused it to be involved?
was its purpose?
other way could it be done?
details could be eliminated?
instructions were not followed?
WHEN
did it occur?
do similar conditions occur?
should it be done?
WHERE
was it?
was its source?
else does it exist?
can I find out?
should it be done?
else is it being done?
HOW
should it be corrected?
can it be avoided in the future?
is the best way to do it?
can it (job or detail) be
improved?
WHY
did it exist?
had no one noticed and
corrected it?
was it being done?
was it being done this way?
was it (job or detail) necessary?
encova.com
WC-5000-FR 07-19
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ENCOVA INSURANCE INJURY KIT (Washington & Jefferson College)

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Completed 28 January 2021

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