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The University of Texas System (University of Texas System)

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The University of Texas System
Employee’s First Report of Work-Related Injury or Occupational Disease
Employee Information
Injured Employee’s Na
me: ______________________________________ Male ( ) Female ( ) Date of Birth: ____/ ____/ ________
Home/Cell Phone: (_____) ______________ Work Phone: (_____) ______________ Preferred Language: ____________________
Employee ID: ____________ Race: Asian ( ) Black ( ) White ( ) Other ( ) Ethnicity: Hispanic ( ) Native American ( ) Other ( )
Work Email Address: _____________________________ Personal Email Address: ________________________________________
Home Address: _________________________________________City: _____________________ State: _______ Zip: __________
Marital Status: Married ( ) Single ( ) Widowed ( ) Spouse’s Name: _______________ ( ) NA # of dependent children? ___ ( ) NA
Position/Title: ________________________Employing Department: _____________________________ Full Time ( ) / Part Time ( )
Incident Information
Location where
this occurrence happened? (Please be specific.) ________________________________________________
Address or name of building / location where this occurrence happened? _________________________________________________
Date of occurrence: ____________ Time of occurrence: ______ ( ) AM ( ) PM Did you notify your supervisor? ( ) Yes ( ) No
Date Supervisor Notified: ________ Time _______ ( ) AM ( ) PM Name of Supervisor: ___________________________________
Were there any witnesses to this occurrence? ( ) Yes ( ) No ______________________________ (_____) ______________
Witness Name Phone
Did you seek medical treatment for this occurrence? ( ) Yes ( ) No If Yes, List name, phone and address of hospital / physician:
___________________________________________________________________________________________________________
*Employees who live in the network service area must seek medical attention from any physician or clinic within the Workers’ Compensation Provider Network
Were days lost
from work due to occurrence (not including injury date)?
( ) Yes ( ) No
Have you returned to work? ( ) Yes ( ) No, Date Returned: ____/ ____/ ________
Please mark the areas of the body picture below that reflect where you
were injured and check the appropriate boxes to the left.
( ) Back
( ) Head Front Vi
ew Back View
( ) Face Right Left Left Right
( ) Neck
( ) Shoulder
( ) Arm
( ) Wrist
( ) Hand
( ) Finger(s)
( ) Ch
est
( ) Abdomen
( ) Ribs
( ) Hips
( ) Buttocks
( ) Thigh
( ) Knee
( ) Leg
( ) Ankle
( ) Foot
( ) Other
The above statement is true and accurate to the best of my knowledge. I confirm that the occurrence described above happened while I was
performing my essential job duties that were assigned to me by The University of Texas System Administration and my employing department.
______________________________
________________________ ___________________________ _________________
Injured Employee’s Signature Date Extension
______________________________________________________ ____________________________ _________________
Supe
rvisor’s Signature Date Extension
Please email the completed First Report of Injury and completed IMO Network
Acknowledgement form to Workers’ Compensation @ bholman@utsystem.edu.
Describe in detail the nature of your i
njury or occupational
disease and how it happened (if more space needed, write on
back of sheet)
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
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The University of Texas System Administration
For more information please contact the Office of Risk Management: Workers’ Compensation Insurance at 512.499.4645
W
orkers’ Compensation Network
Acknowledgement Form
I have received the Notice of Network Requirements which informs me how to get health care
under workers’ compensation insurance.
I
f I am hurt on the job and live in the service area described in this information, I understand
that:
1. I
must choose a treating doctor from the list of physicians in the IMO Med-Select
Network
®
. (A list of physicians can be found at www.injurymanagement.com.) Or, I
may ask my HMO primary care physician to agree to serve as my treating doctor by
completing the Selection of HMO Primary Care Physician as Workers’ Compensation
Treating Doctor Form # IMO MSN-5
.
2. I
must go to my network treating doctor for all health care for my injury. If I need
a
specialist, my treating doctor will refer me. If I need emergency care, I may go
anywhere.
3. The insurance carrier will pay the treating doctor and other network providers.
4. I may have to pay the bill if I get health care from someone other than a network
doctor without network approval.
5. If I receive the Notice of Network Requirements and refuse to sign the
Acknowledgement Form, I am still required to use the network.
P
lease fill out the following information before signing and submitting this completed
acknowledgement form:
N
ame of Carrier:
The University of Texas System
Employee ID #: __________________________ Name of Network: IMO Med-Select Network
®
Hire Date: ______________________________ Department: __________________________
Home Address: ___
_____________________________________________________________
Street Address – No P.O. Box or Work Address
________________________________________
_________________________
City State Zip Code County
_______________________________________________ _____________________
Employee Signature Date
_______________________________________________ _____________________
Printed Name Employee Phone Number
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The University of Texas System Administration
Provider Notification of an on-the-job injury
This form shall act as your notification for your workers' compensation insurance coverage. This form is to be presented
to the physician's office, hospital emergency room, pharmacy or other authorized provider that is treating you for your
work related injury.
If you have any questions regarding your workers’ compensation coverage, please contact the Office of Risk Management
at 512-499-4645
Employer Representative
Phone
Date
Employee Name:
Date of Birth:
Date of Injury:
Provider Instructions
Please submit bills, medical reports,
or questions to:
The University of Texas System
c/o CCMSI
Cannon Cochran Management Services, Inc
P.O.Box 802082
Dallas,TX 75380
PHONE: 1-888-802-0692
FAX: 217-477-6813
E-mail: UTS@CCMSI.com
PLEASE COPY THIS FORM AND RETURN TO EMPLOYEE
This employee has claimed a work related injury and may be covered by
Workers' Compensation Insurance through the University of Texas System.
The University of Texas System Administration is a self-funded employer.
Claims are processed through the University of Texas System in Austin.
It is an administrative violation to bill injured employee directly for Workers’
Compensation treatment. See Section 413.042 of Texas Labor Code.
Pre-Authorization:
For pre-authorization, please call 214-217-5939 or toll-free 888-466-6381 or
fax to 214-217-5937 or 877-946-6638.
THIS FORM DOES NOT CERTIFY COMPENSABILITY OR GUARANTEE PAYMENT
Pharmacy Instructions
Processor: Mitchell
Group: MPS001150TC
PCN: MPS
BIN: 019082
The University of Texas System has partnered with Mitchell ScriptAdvisor to
make filling prescriptions easy.
Please use this form as a temporary prescription card. Please process
prescriptions for the workers' compensation injury only. This form is only
valid if signed and dated by at UT employer representative.
For questions or rejections, please call 877-232-6520. Please DO NOT send
employee home or have employee pay for medication(s) before calling
Mitchell for assistance.
Mitchell Help Desk: 877-232-6520
ID:
Date of injury (MMDDYY)+Date of Birth (MMDDYY)
(ID Example: MMDDYYMMDDYY)
Day Supply is limited to
7 days for a new injury
Injured Employee:
PLEASE KEEP A COPY OF THIS FORM FOR YOUR RECORDS
Please feel free to contact the Office of Risk Management at 512-499-4645 to assist you in locating a workers’ compensation treating
medical provider.
Please take this form and your prescription(s) to a local pharmacy. Mitchell has a network of pharmacies nationwide. If you need
assistance in locating a pharmacy near you, please call Mitchell toll-free at 877-232-6520 or use the "Find a Pharmacy" search
tool at https://www.mitchell.com/products-services/pharmacy-solutions/scriptadvisor.
If you are denied medication(s) at the pharmacy, please call 877-232-6520.
MODIFIED DUTY MAY BE AVAILABLE, PLEASE REACH OUT TO YOUR SUPERVISOR
512-499-4645
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Completed 2 August 2020

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