Fill - Free fillable New Hire Notice -- Injuries Caused By Work (California State University, Los Angeles) PDF form

Page 1

New Hire Notice -- Injuries Caused By Work

What does workers’ compensation cover?

You may be entitled to workers' compensation benefits if

you are injured or become ill because of your job.

Workers' compensation covers most work-related physical

or mental injuries and illnesses. An injury or illness can be

caused by one event (such as hurting your back in a fall)

or by repeated exposures such as hurting your wrist from

doing the same motion over and over). Generally,

independent contractors, and volunteers who receive no

compensation are not covered by workers’ compensation

benefits. If you have questions about coverage, ask your

employer.

What you have to do:

If you have a work injury or illness, immediately notify

your supervisor or your employer representative so that

you can be provided a claim form. Once received complete

the “Employee” section of the claim form and return it to

your employer. Your employer will complete the

“Employer” section and return it to you to submit a copy to

the claims administrator. After review, the claims

administrator will notify you of your eligibility for benefits.

Benefits:

Workers' compensation benefits include: Medical care,

transportation cost, temporary disability, permanent

disability, supplemental job displacement voucher, and

death benefits. All benefits are tax-free.

Medical Care:

You are entitled to medical care that is reasonably

required to cure or relieve you from the effects of your

work-related injury. Medical care may include doctor visits,

hospital services, physical therapy, lab tests, x-rays, and

medicines that are reasonably necessary to treat your

injury. Providers should never bill you directly for work-

related injuries. There is a limit on some medical services.

Your employer is required to provide you with a claim form

within one business day of learning about your injury. It is

extremely important that you complete the “Employee”

section of the claim form as your employer is required to

authorize medical care within one working day after you

file the form. If additional care is necessary after the initial

treatment, the claims administrator will authorize any care

that is appropriate for your injury, including the referral to

specialists.

Your Primary Treating Physician (PTP):

This is the doctor with overall responsibility for treating

your injury or illness. The primary treating physician

determines what type of treatment you need and when

you may return to work. A multispecialty medical group of

licensed doctors and osteopathy can be designated as

personal physicians. If your employer or your employer’s

insurer does not have a Medical Provider Network, you

may be able to change your treating physician to your

personal chiropractor or acupuncturist following a work-

related injury or illness by making a request to the claims

administrator. Chiropractors may not continue as the

primary treating physician after 24 visits. If specialists,

diagnostics, etc. are needed in your case, this physician

will be responsible for making the referrals. If a medical

service requested by your treating physician or another

provider is determined not medically necessary, you will

receive information on how to appeal that decision. If you

choose to appeal you must do so within 30 days of receipt

of the decision.

If you name your personal physician before your injury,

you may see him or her for treatment in certain

circumstances. Otherwise, your employer has the right to

select the physician who will treat you for the first 30 days.

You may be able to switch to a doctor of your choice after

30 days.

Special rules apply if your employer offers a

Health Care Organization (HCO) or has a medical provider

network. You should receive information from your

employer if you are covered by an HCO or MPN. Contact

your employer for more information.

Treatment by your personal physician:

You may be treated by your personal physician if you

notify your employer prior to your injury. A personal

physician includes a medical group of licensed doctors of

medicine or osteopathy. Please have your physician

complete the attached form and return to your employer.

The following requirements must be met:

1. You must have group health coverage from any

source for non-industrial illnesses and injuries.

2. Your personal physician must agree in advance to

treat you for any work injuries or illnesses

3. Your physician must be your regular physician and

surgeon.

4. Your physician has previously directed your medical

treatment and retains your records, including your

medical history.

What happens if your employer disputes your

injury?

State law requires employers to authorize medical care

within one working day of receiving a DWC 1 claim form.

Your employer may be liable for as much as $10,000 in

medical care until your claim is accepted or denied.

Medical Provider Networks:

Your employer may be using a MPN, which is a selected

network of health care providers to provide treatment to

workers injured on the job. If your employer is using a

MPN, a MPN notice should be posted next to this poster to

explain how to use the MPN. If you have predesignated

your personal physician prior to your work injury, then you

may receive treatment from your predesignated doctor. If

you have not predesignated and your employer is using a

MPN, you are free to choose an appropriate provider from

the MPN list after the first medical visit directed by the

employer. If you are treating with a non-MPN doctor for an

Page

existing injury, you may be required to change to a doctor

within the MPN.

What if my employer has a Medical Provider

Network?

If your employer has Medical Provider Network additional

information can be obtained by reviewing the full

employee notification which is required to be posted in

close proximity to the workers’ compensation poster.

What if my employer does not have a Medical

Provider Network?

If your employer does not have a Medical Provider

Network, you may be able to change your treating

physician to your personal chiropractor or acupuncturist

following a work-related injury or illness within 30 days of

reporting your injury. Chiropractors may not continue as

the primary treating physician after 24 visits. You may use

the attached Notice of Personal Chiropractor or Personal

Acupuncturist form to notify your employer of this change.

Emergency Medical Care:

If you need emergency care, call 911 for help immediately

from the hospital, ambulance, fire department or police

department.

First Aid:

If you need first aid treatment, contact your employer. If

you have more than a simple first aid injury, you will need

to ask your employer for a claim form.

Temporary Disability (TD) Benefits:

You may be entitled to payments if you lose wages while

recovering. Your temporary disability rate is calculated by

multiplying your average weekly wage by two thirds. The

first 3 days of disability are not payable under California

law unless there is hospitalization at the time of injury or

the disability exceeds 14 days. If your physician returns

you to work on a modified basis, you may be entitled to

wage loss. This is generally calculated by multiplying the

difference between your average weekly wage and your

earnings during modified duties times two thirds. This is

subject to the benefit minimums and maximums set by the

California Legislature. Temporary disability benefits are

payable within 14 days of the date of injury or knowledge

of the injury. Subsequent payments are due every 14

days. Benefits will continue until your physician states you

may return to work or your medical condition is permanent

and stationary.

For injuries occurring on or after 1/1/08, no more than 104

weeks of temporary disability are payable within 5 years

from the date of injury. For longer term conditions

(hepatitis B & C, amputations, severe burns, HIV, high

velocity eye injuries, chemical burns to the eyes,

pulmonary fibrosis, and chronic lung disease) no more

than 240 weeks within five years from the date of injury

are payable. You may be eligible for state disability

benefits from the Employment Development Department

(EDD) if TD benefits are stopped, delayed, or denied.

There are time limits so contact EDD at (800)480-3287 or

www.edd.ca.gov for information on when and how to

apply.

Permanent Disability (PD) Benefits:

You may be entitled to payments if your physician says

your injury has limited your ability to work. The permanent

disability rate is calculated by multiplying your average

weekly wage by two thirds, subject to statutory minimums

and maximums. The amount of permanent disability or

impairment may depend on your doctor’s opinion, as well

as your age, occupation type of injury and date of injury.

If you have permanent disability or your claims examiner

suspects you have permanent disability, a letter will be

sent to you explaining your benefits, including the estimate

or total value of permanent disability, weekly payment

amount, how the benefit was calculated, and all of your

related rights under the California Labor Code, including

your right to object to the report upon which the

determination is being based. Permanent Disability

benefits are payable within 14 days of the last payment of

temporary disability benefit or after you physician indicates

there is permanent disability. The benefit is payable every

fourteen days. Permanent Disability benefits are not

payable until your claim is finalized if your employer

offered a job upon termination of temporary disability

benefits.

Supplemental Job Displacement Benefit:

You may be entitled to a nontransferable voucher payable

to a state approved school. To qualify, your injury must

result in a permanent impairment and your employer is

unable to offer modified or alternative work within 60 days

of receipt of a report asserting that all medical conditions

have reached maximum medical improvement. If after 60

days after receiving the doctors report your employer has

not offered you regular, modified or alternative work, your

claims administrator has 20 days to provide you

Supplemental Job Displacement Benefits. If you qualify

for the supplemental job displacement benefit, your claims

examiner will provide a voucher for up to $6,000.00. The

voucher may be used for education related retraining

and/or skill enhancement at a state accredited school,

books, required tools, license or certification fees or other

resources that can help you find a new job. There are

limits on how much you can spend on some items, but if

you qualify you will receive a letter with information for

the use of this benefit.

Return to Work Fund

If your injury results in permanent impairment and it is

determined that the amount awarded is disproportionately

low in comparison to your loss of earnings, you may be

entitled to additional compensation. A fund was

established to supplement permanent impairment benefits

under specific circumstances. This fund is administered

by the Division of Workers Compensation. Your examiner

can assist in directing you to the correct resource to

determine eligibility.

Death Benefits:

Death benefits are paid to dependents of a worker who

dies from a work-related injury or illness. The benefit is

Page 3

calculated and paid in the same manner as temporary

disability. This benefit is paid at a minimum rate of $224

per week. The death benefit rates are set by state law and

the amount depends upon the number of dependents. If

dependent minor children are involved, death benefits are

payable at least until the youngest child reaches majority

age. Burial expenses are also provided under this benefit.

Report Your Injury:

Report the injury immediately to your supervisor or to:

Employer representative: _________________________

Phone number: _________________________________

Don't delay. There are time limits. If you wait too long,

you may lose your right to benefits. Your employer is

required to provide you a claim form within one working

day after learning about your injury. Within one working

day after you file a claim form, your employer shall

authorize the provision of all treatment, consistent with

the applicable treating guidelines, for your alleged injury

and shall be liable for up to ten thousand dollars ($10,000)

in treatment until the claim is accepted or rejected. Until

the date the claim is accepted or rejected, liability for

medical treatment shall be limited to ten thousand dollars

($ 10,000). If your claim is denied, you have the right to

appeal the decision within one year of the date of injury.

Discrimination:

It is illegal for your employer to punish or fire you for

having a work injury or illness, for filing a claim, or

testifying in another person's workers' compensation case.

If proven, you may receive lost wages, job reinstatement,

increased benefits, and costs and expenses up to limits set

by the state.

Questions?

If you have questions, see your employer or the claims

examiner who handles workers' compensation claims for

your employer.

Claims Administrator:

Sedgwick Claims Management Services, Inc.

Address: ________________________________________

City:___________________ State: _______Zip: _________

Phone:__________________________________________

The employer is insured for workers’ compensation by:

_______________________________________________

How do I locate information regarding my

employer’s current workers’ compensation carrier?

For information regarding your employer’s workers’

compensation carrier, please visit the below website.

https://www.caworkcompcoverage.com

If the workers’ compensation policy has expired, contact a

Labor Commissioner at the Division of Labor Standards

Enforcement - their number can be found in your local

White Pages under California State Government,

Department of Industrial Relations.

You can get free information from a State Division of

Workers' Compensation Information & Assistance Officer.

The nearest Information & Assistance Officer is at:

Address: ________________________________________

City: _________________ Phone: ____________________

Hear recorded information and a list of local offices by

calling toll-free (800) 736-7401.

Learn more online: www.dir.ca.gov.

False claims and false denials:

Any person who makes or causes to be made any

knowingly false or fraudulent material statement or

material representation for the purpose of obtaining or

denying workers' compensation benefits or payments is

guilty of a felony and may be fined and imprisoned.

Your employer may not be liable for the payment of

workers’ compensation benefits for any injury that arises

from your voluntary participation in any off-duty

recreational, social, or athletic activity that is not part of

your work-related duties.

Denise Watson Cross

323-343-3657

P.O. Box 14629

Lexington KY

40512

916-851-8057

Sedgwick CMS

320 W. 4th Street

Los Angeles

213-576-7335

Page 4

PREDESIGNATION OF PERSONAL PHYSICIAN

In the event you sustain an injury or illness related to your employment, you may be treated for such injury

or illness by your personal medical doctor (M.D.) or doctor of osteopathic medicine (D.O.) if:

On the date of your work injury you have health coverage for injuries and illnesses that are not work related;

The doctor is your regular physician, who shall be either a physician who has limited his or her practice of

medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-

gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your

medical records;

Your "personal physician" may be a medical group if it is a single corporation or partnership composed of

licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group

providing comprehensive medical services predominantly for non-occupational illnesses and injuries;

Prior to the injury your doctor agrees to treat you for work injuries or illnesses;

Prior to the injury you provided your employer the following in writing: (1) notice that you want your

personal doctor to treat you for a work-related injury or illness, and (2) your personal doctor’s name and

business address.

You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor

of osteopathic medicine treat you for a work- related injury or illness and the above requirements are met.

NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee:

Complete this section.

TO: Cal State LA. If I have a work-related injury or illness, I choose to be treated by:

(name of doctor) (M.D., D.O.)

(street address, city, state, ZIP) (telephone number)

Employee Name (please print): ___________________________________________________

Employee’s Address: ___________________________________________________________ ‘

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational

injuries or illnesses:____________________________________________________________

Employee’s Signature: _____________________________________________________Date: _________

Physician: I agree to this pre-designation:

Signature: _______________________________________________________________ Date: _________

(physician or designated employee of the physician)

The physician is not required to sign this form, however, if the physician or designated employee of the

physician does not sign, other documentation of the physician’s agreement to be predesignated will be

required pursuant to Title 8, California Code of Regulations, section 9780.1 (a)(3).

asdfasdf

asdfsdf

asdf

Page

NOTICE OF PERSONAL CHIROPRACTOR OR PERSONAL ACUPUNCTURIST

If your employer or your employer’s insurer does not have a Medical Provider Network, you may be able to

change your treating physician to your personal chiropractor or acupuncturist following a work-related injury or

illness. In order to be eligible to make this change, you must give your employer the name and business

address of a personal chiropractor or acupuncturist in writing prior to the injury or illness. Your claims

administrator generally has the right to select your treating physician within the first 30 days after your

employer knows of your injury or illness. After your claims administrator has initiated your treatment with

another doctor during this period, you may then, upon request, have your treatment transferred to your

personal chiropractor or acupuncturist. Chiropractors may not continue as the primary treating physician after

24 visits.

Note: If your date of injury is January 1, 2004 or later, a chiropractor cannot be your treating physician after

you have received 24 chiropractic visits unless your employer has authorized additional visits in writing. The

term “chiropractic visit” means any chiropractic office visit, regardless of whether the services performed involve

chiropractic manipulation or are limited to evaluation and management. Once you have received 24 visits, if

you still require medical treatment, you will have to select a new physician who is not a chiropractor. This

prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by a surgeon, or physician

designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s

Medical Treatment Utilization Schedule.

You may use this form to notify your employer of your personal chiropractor or acupuncturist.

Your Chiropractor or Acupuncturist’s Information:

(name of chiropractor or acupuncturist)

(street address, city, state, ZIP)

(telephone number)

Employee Name (please print): _____________________________________________________

Employee’s Address: _____________________________________________________________

Employee’s Signature: _______________________________________________________ Date: _________

asdfasdf

asdfsdf

asdf

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

New Hire Notice -- Injuries Caused By Work (California State University, Los Angeles)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank New Hire Notice -- Injuries Caused By Work (California State University, Los Angeles) Form

Related forms

Fillable New Hire Notice -- Injuries Caused By Work (California State University, Los Angeles)

Fill Online, Printable, Fillable, Blank New Hire Notice -- Injuries Caused By Work (California State University, Los Angeles) Form

Related forms

First 20 documents completely FREE!