NORTH EAST FLORIDA EDUCATIONAL CONSORTIUM …
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3-1 NORTH EAST FLORIDA EDUCATIONAL CONSORTIUM www.nefec.org/rmp RISK MANAGEMENT PROGRAM CLAIMS PROCESSING MANUAL Revised September 2016 SECTION III
Transcript of NORTH EAST FLORIDA EDUCATIONAL CONSORTIUM …
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NORTH EAST FLORIDA EDUCATIONAL CONSORTIUM
www.nefec.org/rmp
RISK MANAGEMENT PROGRAM
CLAIMS PROCESSING MANUAL
Revised
September 2016
SECTION III
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CLAIMS HANDLING
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INDEX PAGE
Claims Handling & Claims Services 3.1
Claims Reporting 3.2
Risk Management District Contact Representatives 3.3
General Claims Reporting and Supplemental Reports 3.4
Specific Claim Forms and/or Report Information 3.6
Workers’ Compensation 3.6
Workers’ Compensation Referral for Medical Services Form 3.16
Employer’s Supplemental Report of Injury 3.18
Employee First Aid Log 3.19
Student Accidents 3.20
Recordable Student Accident 3.20
Reportable Student Accident 3.20
Student First Aid Log 3.22
Accident Report – General Liability 3.23
School District Property Loss Report 3.25
Automotive 3.27
Accident Report, Auto or Truck 3.27
School Bus Accident 3.27
Supervisor’s Corrective Action and Accident Report 3.31
Emergency Numbers 3.33
Risk Management Program Supply Order Form 3.34
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CLAIMS HANDLING
Prompt, accurate and complete claims’ reporting is a major key to a successful Risk Management Program. It is the philosophy of NEFEC staff members and our Service Organization that our services to participating school districts depend on how quickly we are notified that a claim has been generated in your district. Early claim reporting generally improves the financial impact of the settlement and often avoids the development of hostile attitudes that can lead to unnecessary claims cost. PLEASE KEEP IN MIND THAT THE COMPLETION OF A CLAIM FORM DOES NOT ADMIT TO THE LIABILITY OF A SCHOOL DISTRICT FOR AN ACCIDENT. PROMPT AND ACCURATE DOCUMENTATION OF THE CIRCUMSTANCES SURROUNDING THE ACCIDENT MIGHT MINIMIZE OR REMOVE A SCHOOL DISTRICTS LIABILITY. The responsibility for the initial reporting, completion and distribution of claims rests with each cost center within a school district. Each district has a Risk Management District Contact Person. With their help and the NEFEC staff, in-service workshops can be conducted to assist in the important task of claims reporting. In this Claims Handling Manual are detailed instructions on how and when specific types of claims should be reported; how completed claim forms should be distributed; sample claim forms and reports; and additional relevant information.
CLAIMS SERVICE The Consortium has entered into a service agreement with Johns Eastern of Sarasota, Florida. After a claim has been opened it may be necessary for them to contact your school district or you to contact them. Please keep in mind that they are working for your district and all participating school districts in our program. Your full cooperation and prompt response to their inquiries will be appreciated and assist them and this office to do a better and more efficient job for you.
THEIR MAILING ADDRESS AND TELEPHONE NUMBERS ARE:
WORKERS” COMPENSATION Johns Eastern Co., Inc. – P.O. Box 110279-Lakewood Ranch, FL 34211
1-800-749-3044 FAX - 941-527-4040
PROPERTY/LIABILITY
Johns Eastern Co., Inc. – P.O. Box 110279-Lakewood Ranch, FL 34211 1-800-749-3044
FAX – -1-866-907-8986
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SERVICE REPRESENTATIVES ARE:
Account Administration Personnel – (800) 749-3044 Johns Eastern Co., Inc. – P.O. Box 110259-Lakewood Ranch, FL 34211
Alice Bane Director of TPA Operations [email protected] Ext. 1341 Meagan Pfahler Administrative Assistant [email protected] Ext. 1378 Greg Burden Quality Assurance Manager [email protected] Ext. 1353
Information Services – (800) 749-3044
Jason Ricci Manager [email protected] Ext. 1905 Sean Downey Supervisor [email protected] Ext. 1918
Workers’ Compensation Claims Personnel – (800) 749-3044 FAX – (941) 527-4040 Johns Eastern Co., Inc. – P.O. Box 110279-Lakewood Ranch, FL 34211
Amanda Radcliffe Claims Manager [email protected] Ext. 1385 Jessica Rinehart Assist. Claims Manager [email protected] Ext. 1358 Reese Gardiner Claims Supervisor [email protected] Ext. 1376 Aimee Aberg Senior Adjuster [email protected] Ext. 1398 Tory King Lost Time Claims Adjuster [email protected] Ext. 1328 Jessica Stroup Medical Only Adjuster [email protected] Ext. 1346
Medical Management Services – (800) 749-3044 FAX – (941) 527-4040
Linda Trefethen Quality Assurance Supervisor [email protected] Ext. 1331 Heather Keegan Nurse Case Manager [email protected] Ext. 3404
Liability Claims Personnel – (800) 749-3044 FAX – (941) 527-4040 Johns Eastern Co., Inc. – P.O. Box 110239-Lakewood Ranch, FL 34211
Jim Boelter Liability Quality Assurance Manager [email protected] Ext. 1102 Nick Mullins Liability Claims Manager [email protected] Ext. 1406 Chris Jackson Liability Claims Supervisor [email protected] Ext. 1411 Lynn Manigault Lead Liability Adjuster [email protected] Ext. 1407 Tahri Beltinck Liability Adjuster [email protected] Ext. 1416
NEFEC RISK MANAGEMENT PROGRAM STAFF (386) 329-3842 FAX (386) 329-3835
3841 Reid Street, Palatka, Florida 32177
Steven O. Henderson Director, Risk Management Services [email protected] Russ McIntire Loss Prevention and Safety Specialist [email protected] Stephanie Simonds Senior Claims Representative [email protected]
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PROCEDURES FOR REPORTING WORKERS’ COMPENSATION CLAI MS
JOHNS EASTERN FOR NEFEC
NON-EMERGENCY INJURIES EMPLOYEE SUSTAINS A NON-EMERGENCY WORK PLACE INJURY
EMPLOYEE REPORTS INJURY TO EMPLOYER
EMPLOYER DIRECTS EMPLOYEE TO NEAREST, APPROPRIATE JOHNS EASTERN MEDICAL CARE COORDINATOR (MCC). NOTE: THE REFERRAL FOR MEDICAL SERVICES FORM IS
REQUIRED.
EMPLOYER COMPLETES NOTICE OF INJURY ON LINE VIA www.johnseastern.com WITHIN 24 HOURS
EMERGENCY INJURIES
REMPLOYEE REPORTS INJRUY TO EMPLOYER
EMPLOYER FACILITIATES TRANSPORTATION OF EMPLOYEE TO CLOSEST EMERGENCY FACILITY AND CALLS JOHNS EASTERN MANAGED CARE AT
1-800-749-3044
EMPLOYER COMPLETES NOTICE OF INJURY ON LINE VIA www.johnseastern.com
WORKERS’ COMPENSATION Complete all Workers’ Compensation claims on line via www.johnseastern.com. Click on login iApps (Notice of Injury DWC-1(3/09). Fax Wage Statement (DWC-1a (3/09) to 941-527-4036 (DO NOT MAIL. KEEP ORIGINAL AND CARRIER COPY) Mail all medical bills, doctor statements and any workers’ compensation related documents to:
Johns Eastern Co., Inc. – P.O. Box 110279, Lakewood Ranch, FL 34211
ALL OTHER CLAIMS SCHOOL BUS, PROPERTY, LIABILITY, AUTO, ETC.
SEND by U.S. Mail or fax 386-329-3835 or email Steve Henderson, North East Florida Educational Consortium
3841 Reid Street, Palatka, FL 32177 Telephone 386-329-3842
Fax 386-329-3835 www.nefec.org/rmp
Email – [email protected] Email – [email protected]
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RISK MANAGEMENT DISTRICT CONTACT REPRESENTATIVES
Denny Wells Baker County Schools 392 S. Blvd. East Macclenny, FL 32063 904-259-5420 [email protected]
Tammy Beauchamp Gilchrist County Schools 310 N.W. 11th Avenue Trenton, FL 32693 352-463-3205 [email protected]
Randy Whytsell Bradford County Schools 501 West Washington Street Starke, FL 32091 904-966-6810 [email protected]
Mary Loughran Hamilton County Schools 5683 US Hwy 129, Suite 1 Jasper, FL 32052 386-792-3900 [email protected]
Keith Hatcher Columbia County Schools 372 West Duval Street Lake City, FL 32055 386-755-8034 [email protected]
Awilda Fonte Hernando County Schools 919 North Broad Street Brooksville, FL 34604 352-797-7247 [email protected]
Jerry Evans Dixie County Schools 16077 NE 19 Hwy, Bldg. 20 Cross City, FL 32628 352-498-6150 [email protected]
Kalee Wade Levy County Schools P.O. Drawer 129 Bronson, FL 32621 352-486-5231 [email protected]
April Dixon Flagler County Schools P.O. Box 755 Bunnell, FL 32110 386-437-7526 [email protected]
Sue Farmer Nassau County Schools 1201 Atlantic Avenue Fernandina Beach, FL 32034 904-491-9861 [email protected]
Nate Askew Florida Virtual School 2145 Metro Center Blvd., Suite 200 Orlando, FL 32835 407-513-3587 [email protected]
Debra Shepard Putnam County Schools 200 Reid Street Palatka, FL 32177 904-329-0549 [email protected]
Marie Pittman Union County Schools 55 S.W. Sixth Street Lake Butler, FL 32054 386-496-2045 [email protected]
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GENERAL CLAIMS REPORTING AND SUPPLEMENTAL REPORTS
CLAIMS ARE DIVIDED INTO THE FOLLOWING 5 CATEGORIES
Form Number 1. Workers’ Compensation (State Form-Notice of DWC-1 (03/09)
Injury and Wage Statement) DWC-1a (03/09)
2. General Liability R/M 5 (R-7/95)
3. School District Property Loss Notice R/M 6 (R-7/03) 4. Vehicle
a. Auto or Truck R/M 9 (R-8/95)
b. School Bus R/M 1 (R-7/95)
5. Student Accident/Injury Report R/M 3 (R-7/09)
SUPPLEMENTAL REPORTS ARE DIVIDED INTO THE FOLLOWING CATEGORIES: 1. Workers’ Compensation
a. Workers’ Compensation Referral For Medical R/M 8 (R-6/99) Services Form
b. Supervisor’s Injury Investigation-- R/M 7 Strain Supplement (White)
c. Employer’s Supplemental Report of Injury R/M BCL-3 2. First Aid Logs
a. Employees (White) R/M 15 (R-6/90)
b. Students (White) R/M 11 3. Miscellaneous Reports
a. Supervisor’s Corrective Action and R/M 2 (R-8/94) Accident Investigation (White)
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EVERY ACCIDENT SHOULD BE REPORTED ON THE APPROPRIAT E CLAIM FORM
Detailed documentation of the occurrence is important as are the supplemental reports. Time spent in
completing these claims forms and supplementary reports, promptly and accurately, can protect your
school district, its employees, our loss fund and will facilitate claims adjustment and settlement.
KNOWLEDGE OR INFORMATION CONCERNING ACTUAL OR THREATENED LEGAL
ACTION SHOULD BE TRANSMITTED TO THE CONSORTIUM RISK MANAGER’S OFFICE. NO
STATEMENTS OR INFORMATION SHOULD BE GIVEN TO OUTSIDE PERSONS WITHOUT
PRIOR DISCUSSION WITH THE CONSORTIUM RISK MANAGER AND JOHNS EASTERN
COMPANY, INC.
Serious claims and/or claims of an emergency nature should be reported by telephone to the Consortium
Risk Manger’s office, phone number 386-329-3842. If you are unable to contact anyone at this office
then telephone contact should be made to Johns Eastern Company, Inc. 800-749-3044. Completed
appropriate claims notice or report form should follow as soon as possible to NEFEC.
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SPECIFIC CLAIM FORMS AND/OR REPORT INFORMATION
WORKERS’ COMPENSATION
NOTE AND PLEASE READ CAREFULLY
The majority of a school district’s claims will be in this area—Workers’ Compensation. It is most important (and the law) that the (Florida) statutory procedures be followed in a TIMELY and ACCURATE manner. PLEASE FOLLOW THESE INSTRUCTIONS FOR SUBMITTING WOR KERS’ COMPENSATION CLAIMS – PLEASE NOTE: The Workers’ Compensation laws of Florida are specific with regards to filing of workers’ compensation claims.
1) A NOTICE OF INJURY (see page 3.11) must be completed when an employee is injured “on the job” AND such injury may cause the employee to lose more than seven (7) days of work and/or the employee WILL BE authorized to seek medical treatment.
2) The Notice of Injury MUST BE COMPLETED ON LINE VIA www.johnseastern.com within seven (7) days after the employee has reported the accident or after the employer has first knowledge of the accident. FAILURE TO DO SO WILL RESULT IN A FINE OF UP TO $500 PAYABLE BY THE DISTRICT.
3) When the employer authorizes immediate medical treatment a copy of R/M 8 (R-6/99). Workers’
Compensation Referral for Medical Services Form (See page 3.16) should be mailed to NEFEC when returned by the employee.
An accident should be documented on R/M 15 (R-6/90), EMPLOYEE FIRST AID LOG. (see page 3.19) if all of the following are applicable.
1) The employee is injured in any manner and to any degree on the job and reports the injury to their supervisor.
2) The injury will not cause the employee to lose time from their job.
3) The employee does not intend to seek outside medical attention for the injury. (see page 3.10 for more details).
THE ACCURACY AND DETAILED COMPLETION OF THE NOTICE OF INJURY REPORT AND REFERRAL FOR MEDICAL SERVICES FORM WILL ASSIST THE EMPLOYEE, THE EMPLOYER (SCHOOL DISTRICT) AND NEFEC IN PROMPT HANDLING OF WORKERS’ COMPENSATION CLAIMS.
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MEDICAL BILLS Receipt of any and all medical bills received by the employer (school district) should be sent immediately to Johns Eastern. There is a penalty imposed by the Dept. of Labor & Employment Security if this procedure is not followed promptly. REFERRAL FOR MEDICAL SERVICES (see page 3.16) Employee must be referred to an authorized medical facility for treatment appropriate to the injury sustained. Use the Medical Referral For Services Form #R/M 8 (R-6/99) when referring employee for treatment. SUPERVISOR’S INJURY INVESTIGATION—STRAIN SUPPLEMENT (see page 3.17) For all cases involving back injury, suspected hernia, or other unusual sprain, a Supervisor’s Injury Investigation-Strain Supplement Form (R/M 7) must be completed. The Risk Management District Contact Person is then responsible for having the appropriate supervisor complete the form. Copies are to be forwarded to the Risk Management Office (NEFEC). SUPERVISOR’S CORRECTIVE ACTION AND ACCIDENT INVESTI GATION REPORT (see page 3.32) Following all accidents, a Supervisors’ Corrective Action and Accident Investigation Report (Form R/M 2 R-8/94) must be completed by the supervisor or principal, with copies forwarded to the Risk Management office and school district office. One copy will be retained in the files of the supervisor or principal who will do a follow-up investigation to assure that remedial steps have been taken. Careful attention should be given to the “remedy” offered by the supervisor. All accidents are preventable and some type of realistic remediation should be stated. WORKERS” COMPENSATION CLASSIFICATION CODES: 8868—Professional, instructional. Teachers, teacher’s aides, superintendents, principals, counselors, clerical staff, etc. 7383—Bus Drivers, Mechanics 9101—All Others To be in compliance with the Florida Workers’ Compensation Law a classification code number should follow the claimant’s occupation in the appropriate space on the Notice of Injury form.
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VOLUNTEERS Volunteers who are injured “on the job” should be logged on the Employee’s First Aid Log if they are NOT intending to seek outside medical treatment. Chaperones may not be considered volunteers. Please contact NEFEC/Risk Management Program or Johns Eastern if you have a question. If the injury is serious and outside medical services are required, the regular Notice of Injury Report should be completed. NOTE: on this form (DWC-1) some of the information required for an employee is not applicable for a volunteer. In the space “Occupation” type Volunteer. No classification number is necessary. However, in the “Comments” section explain to what the claimant was volunteering; which class, what program or activity. The following partial facsimile of the Notice of Injury (see page 3.15) indicates those areas which at this time, are not applicable to volunteers. If possible, form R/M 8 (R-6/99), Workers’ Compensation Referral For Medical Services Form, should be utilized. Also, again if possible, encourage the volunteer (claimant) to return this form to the school district.
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WORKERS’ COMPENSATION REFERRAL FOR MEDICAL SERVICES FORM (R/M 8 R-6/99) (see page 3.16)
UNAUTHORIZED MEDICAL TREATMENT The Workers’ Compensation Law is quite clear in specifying that the employee is not responsible for unauthorized medical expenses unless the employer fails to provide medical treatment. Any unauthorized medical treatment is at the expense of the employee. The injured employee is required to use the doctor that you authorize. IT IS ESSENTIAL THAT ALL EMPLOYEES BE INFORMED OF THE IMPORTANCE OF IMMEDIATELY REPORTING ALL ACCIDENTS, PARTICULARLY THOSE THAT REQUIRE OUTSIDE MEDICAL ATTENTION. Originals of any medical bills or reports that are received directly by the employer are to be mailed IMMEDIATELY to JOHNS EASTERN. SERIOUS INJURIES When an accident results in an injury to an employee while the employee is performing the duties of his/her employment, the seriousness of the injury dictates the course of action to be taken. If the injury is of a serious nature, emergency help should be summoned by the supervisor or principal, or the employee should be taken to the nearest medical facility – depending on the circumstances. When emergency help is called by the supervisor or principal, someone should be assigned to stand by to meet them and direct them to the location. On any claim of a serious nature the injured employee’s family should be notified and advised what action has been taken. A mode of transportation should also be established in the event the injured employee is unable to operate his or her own vehicle or does not have private transportation. The Risk Manager’s office should be notified by telephone of any serious accident. In the event you are unable to reach the Risk Manager or the Risk Management office, please call the Johns Eastern office (see page 3.1). The completed appropriate claim notice or report should follow as soon as possible to NEFEC. NOTE: DO NOT HOLD UP THE NOTICE OF INJURY REPORT B ECAUSE THE EMPLOYEE IS NOT ABLE OR PRESENT TO SIGN.
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EMPLOYER’S SUPPLEMENTAL REPORT OF INJURY (R/M-BCL-3 ) (see page 3.18) This form is to be completed. 1. Immediately after the employee returns to work if the Notice of Injury (Form DWC-1) did not show
that the injured employee returned to work. 2. In the event the employee returns to work and then begins to lose additional time due to the same
accident, use “Remarks” section of R/M BCL-3 to report additional lost time from work.
3. After submission of the Notice of Injury, immediate notification by telephone to NEFEC Risk Manager is necessary if death occurs. In the event you are unable to reach the Risk Manager or Risk Management office, please call the Johns Eastern office (see page 3.1). The completed appropriate claims notice or report should follow as soon as possible to Johns Eastern and/or NEFEC.
4. If an employee is terminated during a disability period.
5. If an employee resigns. This report is self-explanatory and should be signed by the supervisor, principal or personnel department. This form should be typed; all copies legible. These forms can be obtained from the Consortium’s Risk Management office. Distribution should be as follows: NEFEC – Original and 1 copy School District – 1 copy EMPLOYEE FIRST AID LOG (R/M 15 R-6/90) (see page 3.19) Each school district cost center should maintain a 3 ring notebook as an Employee’s First Aid Log (R/M 15 R-6/9). If an employee sustains a minor injury on the job, which requires only first aid treatment*, this log should be completed. Employees should be informed that seeking first aid treatment for a minor injury does not preclude or jeopardize their right to obtain outside medical treatment and/or compensation for lost working time at some later date for this injury. This log is an important (and legal) report. If an employee qualifies (see page 3.6), a workers’ compensation Notice of Injury Report should be completed even though the initial treatment was first aid. The date first aid treatment was provided should be noted in the “comments” section of form DWC-1 (Notice of Injury). *First aid treatment means no outside medical care is needed and/or no lost time from work (more than 7 days).
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PROCEDURES TO COMPLETE NOTICE OF INJURY DWC-1 (11/94) EMPLOYEE INFORMATION SECTION
Use this as a guide to complete the NOI on-line at www.johnseastern.com . Click on login 1APPS. 1. Name – the injured workers’ first, middle and last name. 2. Home address – the injured worker’s complete mailing address. 3. Telephone – the injured worker’s home telephone number including the area code. 4. Occupation – the injured worker’s job title and workers’ compensation classification code. (see page
3.7). 5. Date of Birth – the injured worker’s birthdate, month, day and year. 6. Sex – the sex of the injured worker, check “M” if mail, check “F” if female. 7. Social Security Number – the injured worker’s social security number, if the employee does not have
a social security number contact your adjuster at Johns Eastern. 8. Date of Accident – the exact month, day and year according to the injured employee. 9. Time of Accident – the approximate time of the accident according to the injured employee. 10. Employee’s Description of Accident – the employee’s account of how the injury occurred. (attch
description to Notice of Injury, if necessary). 11. Describe Injury or Illness that occurred – explain the physical injuries or illnesses. 12. Describe the part of the body affected.
EMPLOYEE INFORMATION SECTION 1. District’s Name and Mailing Address – the school district’s complete name, do not abbreviate or use
shortened version; D.B.A. (doing business as) the school or cost center name; the school district’s complete street and mailing address.
2. Telephone – the school district’s telephone number including the area code. 3. Employer’s Location Address – name and address of school or cost center where the employee is
assigned. 4. Place of Accident – employee’s assigned cost center. Put location code # and complete name and
address. 5. Federal Employer I.D. Number – the employer’s identification number assigned by the U.S.
Government for tax and unemployment compensation purposes. 6. State the nature of your business – (education). 7. Date Employed – the first day that the injured employee worked for the employer. 8. Lade Date Employee Worked – the last day the injured employee reported to work. 9. Returned to Work – check “yes” or “no” and, if yes, give date that employee returned to work. 10. Date of Death (if applicable).
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11. Agree with this Description of Accident – check “yes” if you agree with the employee’s account of how the accident occurred, check “no” if you disagree with the employee’s account or that an accident happened and explain why you disagree.
12. Date First Reported – the exact DATE when you or any of your supervisor’s had knowledge that an accident occurred.
13. Policy/Member Number – put N/A. 14. Was employee paid for the day the accident occurred? Check yes or no. 15. Will you continue to pay Salary – check “yes”. 16. Rate of Pay – the employee’s exact rate of pay in dollars and cents, check “HR” if the amount is paid
by the hour, check “WK” if the amount is paid by the week, check “DAY” if the amount is paid by the day, check “MO” if the amount is paid by the month. Enter the number of hours worked per day, the number of worked per week and the number of days worked per week.
17. Name, Address and Phone Number of Physician or Hospital – the complete mailing address and telephone number with area code for the hospital or physician that treated the injured worker. Was above Physician/Hospital authorized by Employer – check “yes” if you approved this treatment, check “no” if you did not approve this treatment.
18. Employer Signature – you must sign your name and date the form when y 9ou complete this Notice of Injury. Employee signature and date – have the injured worker sign and date the form, if the employee is unavailable note “not available to sign.”
CARRIER INFORMATION SECTION
WILL BE COMPLETED BY JOHNS EASTERN
• TO AVOID A FINE OF UP TO $500, you must complete this DWC-1 and submit to Johns Eastern, WITHIN SEVEN (7) DAYS OF YOUR KNOWLEDGE of an industrial accident which will require medical treatment.
• The “Employee” copy MUST be furnished to the injured worker when you submit the Notice of Injury (NOI).
• If the employee is not available to sign, do not delay filing this report, state that employee is “not available to sign” and mail the “employee” copy.
• Deaths must be reported by telephone 1-800-219-8953 or telegraph directly to the Division of Workers’ Compensation within 24 hours if the Notice of Injury has not been processed. Also, this “Notice of Injury” must be sent as specified above.
• Prompt and appropriate medical treatment should be provided to the injured employee when requested or seem to be necessary.
• The EMPLOYER has the right to select the physician. • Refusal or failure to authorize medical treatment may result in the employee seeking treatment
on his or her own at your expense. • The filing of the DWC-1 must not be delayed while you obtain accurate wage information for the
DWC-1a. DWC-1a completed on Lost Time claims only. A Lost Time claim is one where an employee misses more than seven (7) days.
• TO AVOID A FINE OF UP TO $100, the DWC-1a must be completed and forwarded to the carrier within fourteen (14) DAYS. A copy MUST be given to the employee.
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http://www.myfloridacfo.com/wc/pdf/DFS-F2-DWC-1.pdf
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Telephone 941-361-3100 � Toll Free 1-800-749-3044 � Toll Free Fax 1-888-405-3100
NORTHEAST FLORIDA EDUCATIONAL CONSORTIUM (NEFEC)
REFERRAL FOR MEDICAL SERVICES FORM
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This is a temporary workers’ compensation program I.D. Form. This form is not a guarantee of eligibility for workers’
compensation benefits.
SECTION 1 – To be completed by EMPLOYER EMPLOYER NAME: EMPLOYEE NAME: SOCIAL SECURITY #: DATE OF INJURY: PLACE OF INJURY: STATE BODY PART INJURED: ISSUED BY:
IMPORTANT INFORMATION FOR HOSPITALS AND PHYSICIANS Johns Eastern Company’s Managed Care Department has been engaged by NEFEC to administer their Managed Care Arrangement under Florida Statute 440. You are presently treating the above employee for an injury alleged to have occurred during his/her employment with the aforementioned employer. We call to your attention that “light duty” may be available in conjunction with ON-THE-JOB injuries. YOU MUST CALL Johns Eastern Company at (800) 749-3044 prior to any treatment / admission other than an emergency situation. In an emergency, you must call within 24 hours of treatment. SEND BILLS TO: JOHNS EASTERN COMPANY, INC. P. O. BOX 110279 LAKEWOOD RANCH, FL 34211
SECTION II – To be completed by HEALTH CARE PROVIDER NAME OF INJURED EMPLOYEE: DATE OF TREATMENT: DATE OF APPOINTMENT FOR FURTHER TREATMENT: DIAGNOSIS: REMARKS BY M.D. MAY RETURN TO WORK: DATE: REGULAR: RESTRICTIONS: RESTRICTIONS: NAME OF TREATING PHYSICIAN: (Please Print Full Name) SIGNATURE OF TREATING PHYSICIAN:
PLEASE COPY TO: 1. Johns Eastern Company 2. Employer Copy 3. Medical Provider Copy
4. NEFEC 4/M 8 Revised 5-99
FLORIDA � MARYLAND � PENNSYLVANIA � VIRGINIA � WASHINGTON, D.C.
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SUPERVISOR’S INJURY INVESTIGATION-STRAIN SUPPLEMENT
Employee Name: Date of Injury: Location Code: Complete as a supplement to R/M 2 Supervisor’s Investigation Report, in cases involving complaint of back injury, suspected hernia, or other unusual strain. This is an Interrogation Report. Ask these questions as soon as possible after receiving report of injury. The purpose of this supplement is to assist you in developing a clear understanding of strain incidents. 1. Did the pain develop gradually, or did you feel it all of the sudden?
IF THE PAIN WAS ACUTE (SUDDEN), USE QUESTIONS 2-7 2. Exactly what were you ding when the pain was felt? 3. Have you ever done this before? If so, how often? 4. When you felt the pain, were you doing it the way you usually do it? If no, what
was different? 5. Did anything unexpected, unusual or abnormal happen? Explain. 6. When you feel the pain, did you tell anyone? If so, who and when? 7. If nothing unexpected or unusual happened, how do you think the injury occurred? How would you explain why you were
injured?
IF THE PAIN DEVELOPED GRADUALLY< USE QUESTIONS 8-14 8. When did you first notice the pain? 9. What had you been doing that you feel caused the pain? 10. How long, or how many times did you do this? 11. Have you ever done this before? If so, how often? 12. Were you doing it the same you usually do it? If not, what was different? 13. Except for the pain that developed, do you recall anything unusual, unexpected or abnormal that happened? 14. If nothing unusual happened, what do you think caused the pain? How would you explain why you were injured? Supervisor’s Signature Date of Report Distribution: NEFEC 1, School District 1 R/M 7
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EMPLOYER’S SUPPLEMENTAL REPORT OF INJURY NEFEC/RMP
3841 REID STREET PALATKA, FLORIDA 32177
DISTRICT COST CENTER EMPLOYEE’S NAME SOCIAL SECURITY # COST CENTER’S ADDRESS EMPLOYEE’S PRESENT ADDRESS DATE OF ACCIDENT Phone #: Phone #: DATE OF WEEK ACIDENT OCCURRED HOUR OF DAY A.M. P.M. DATE EMPLOYEE’S DISABILITY BEGAN . HAS EMPLOYEE RETURNED TO WORK? . IF “YES”, ENTER DATE RETURNED IS EMPLOYEE EARNING SAME WAGES AS BEFORE INJURY? . IF “NO”, PLEASE EXPLAIN IF DISABILITY HAS NOT TERMINATED, STATE PROBABLE DATE OF TERMINATION HAS THE EMPLOYEE DIED? . IF “YES”, ENTER DATE OF DEATH REMARKS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECIEVE ANY EMPLOYER OR EMPLOYEE, INSURANCE COMPANY, OR SELF-INSURED PROGRAM FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS GUILTY OF A FELON OF THE THIRD DEGREE. PREPARED BY (SIGNATURE) POSITION DATE THIS REPORT COMPLETED R/M-BCL-3 R-8/90
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EMPLOYEES FIRST AID LOG
DISTRICT: LOCATION CODE: PAGE NUMBER:
DATE OF ACCIDENT
EMPLOYEE’S NAME AND
SOCIAL SECURITY #
MALE/ FEMALE PLEASE CIRCLE
EMPLOYEE’S SIGNATURE
DATE & TIME
INJURY REPORTED
EMPLOYEE’S DESCRIPTION OF
ACCIDENT – INCLUDE PART OF BODY AFFECTED
DESCRIPTION OF FIRST AID
TREATMENT & NAME OF PROVIDER
EMPLOYER AGREES
WITH DESCRIPTION
YES/NO
DATE OF
RETURN TO
WORK
W/C CODE AND
OCCUPATION
M/F YES/NO
M/F YES/NO
M/F YES/NO
R/M 15 R-6/90
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STUDENT ACCIDENTS
Student accidents fall within two classifications: 1) Recordable and 2) Reportable.
1. RECORDABLE STUDENT ACCIDENT (R/M 3 R-7/90) A recordable student accident is if the accident results in: a. Student injury severe enough to cause the loss of one-half day or more of school time. b. Student injury severe enough to cause the loss of one-half day or more of student activity
during non-school time. c. Student injury requiring treatment by a doctor, emergency personnel, or a student is sent home
or taken home by a parent or guardian.
In the event of a recordable student accident, form R/M 3 R-7/09 should be completed accurately and promptly following the accident and mailed to NEFEC/Risk Management Program as they occur. No one should admit or commit to the responsibility or liability of the school district, but the legal doctrines of the failure to warn and lack of supervision do apply to student accident. School districts are mandated to provide a safe educational environment for all students at all times and under all circumstances. The distribution of Form R/M 3 R-7/09 is as follows: 1 copy to NEFEC – 1 copy to School District – 1 copy to Student’s Principal
2. REPORTABLE STUDENT ACCIDENT A reportable student accident is if the accident does not cause a loss time injury or medical treatment. Reportable student accidents should be reported on the student first aid log R/M 11.
STUDENT FIRST AID LOG R/M 11
Many student “accidents’ are minor, therefore, are reportable. Florida School Board Rules mandate that documentation be kept regarding all first aid treatment provided to a student. This First Aid Log should be kept at each cost center where students could obtain first aid treatment. This log could provide legal substance to faculty members and a school district should a student accident subsequently develop into a legal matter.
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STUDENT FIRST AID LOG
DISTRICT: LOCATION CODE: PAGE NUMBER:
TODAY’S DATE
STUDENT’S NAME
MALE/ FEMALE PLEASE CIRCLE
AGE GRADE DATE OF
ACCIDENT BRIEF DESCRIPTION OF
ACCDIENT
DESCRIPTION OF FIRST AID
TREATMENT & NAME OF
PROVIDER
BRIEF DESCRIPTION OF FIRST AID TREAMENT
SIGNATURE OF PERSON PROVIDING
FIRST AID
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
Male/Female
R/M 15 R-6/90
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ACCIDENT REPORT – GENERAL LIABILITY (R/M 5 R-7/95)
This report is for accidents where someone, other than a school district employee, is injured or their property is damaged. The more accurately and promptly this form is completed, the sooner a judgment can be made regarding the school district’s responsibility and liability. Please keep in mind that the school district’s responsibility and liability is not automatic. Legally you should never admit or commit the school district’s responsibility or liability for an accident. Distribution of this claim form, as soon as possible following the accident is: 1 copy to NEFEC 1 copy to School District
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NEFEC/RMP Accident Report-General Liability
Instructions: Prepare in triplicate. Send the WHITE copy to NEFEC/RMP, the canary copy for school files and the pink copy to the district safety officer. Use this form to report all accidents where someone, other an a school district employee or student, is injured or their property is damaged. DO NOT ADMIT LIABILITY OR COMMIT THE SCHOOL DISTRICT’S REPSONIBILITY FOR THE ACCIDENT . Accident Reports-General Liability should be sent immediately to the NEFEC/RMP. Attach supporting documentation including repair estimates, bills, newspaper articles, statements, photographs and police reports. PRINT or TYPE so all copies are legible.
(Name) School District:
Name of School:
(6 digit) Location Code:
(Where Loss Occurred)
Date of Loss:
Time of Loss: am / pm
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SCHOOL DISTRICT PROPERTY LOSS NOTICE (R/M 6 R-7/03)
This loss report is not for automobile, truck or school bus accidents. Accuracy and promptness with these types of losses will assist timely settlement with a school district. It is important that “persons notified of loss” reports be submitted as soon as possible following loss. Your estimate of value of property loss is also important. Internal work orders or tickets to repair damaged property are part of this loss report and should be included. District is as follows: 1 copy to NEFEC 1 copy to School District
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VEHICLE
ACCIDENT REPORT – AUTO OR TRUCK (R/M 9 R-8/95)
Accuracy and promptness with this report will expedite settlement. Include all supporting documentation, i.e. police reports, repair estimates of the school district’ auto or truck. Distribution is as follows: 1 copy to NEFEC 1 copy to School District 1 copy to Transportation Department
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SCHOOL BUS ACCIDENT REPORT FORM (R/M. 1 R-7/95)
This report is in compliance with Florida Statutes. It should be completed accurately and promptly following an accident involving a school bus. Do not hold up filing this report for the list of students on the bus at the time of the accident as well as photos and police report. The student list can follow this report in a timely manner. Also, please send all documentation and supplemental reports as soon as available following the accident. Distribution of a school bus accident, student list, documentation and report is as follows: 1 copy to NEFEC 1 copy to School District 1 copy to Transportation Department
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SUPERVISOR’S CORRECTION ACTION AND ACCIDENT REPORT (R/M 2 R-8/94)
This report should be completed promptly following these types of accidents:
1. Workers’ Compensation
2. General Liability
3. Automobile and Truck
4. School Bus Accident
5. Recordable Student Accident Distribution is as follows: 1 copy to NEFEC 1 copy to School District 1 copy to School Principal
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PLEASE COPY AND POST
EMERGENCY NUMBERS
EMERGENCY RESCUE: AMBULANCE: FIRE: POLICE: DOCTOR/CLINIC: HOSPITALS: MAKE IT A POINT TO LOOK UP AND RECORD THE EMERGENCY NUMBER YOU MAY NEED.
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RISK MANAGEMENT PROGRAM SUPPLY ORDER FORM NUMBER REQUESTED Claims Processing Manual Notice of Injury/Workers’ Compensation Claims-DWC-1 (3/09) Employer’s Supplementary Report of Injury-W/C Claims R/M BCL-3 School Bus Accident Report Form – R/M 1 R-7/95 Supervisor’s Corrective Action & Accident Investigation Report – R/M 2 R-8/94 Recordable Student Accident Report – R/M 3 R-7/09 Accident Report – General Liability – R/M 5 R-7/95 School District Property Loss Notice – R/M 6 R-7/03 Supervisor’s Injury Investigation—Strain Supplement – R/M 7 Workers’ Compensation Referral For Medical Services Form – R/M 8 R-6/99 Accident Report, Auto or Truck – R/M 9 R-8/95 Employee First Aid Log – R/M 15 R-6/90 Student First Aid Log – R/M 11 Supply Order Form – R/M 1 R 7/93 State of Florida Workers’ Compensation Form Off Campus School Activity Consent Form – R/M 21 Medical Authorization – R/M 22 Acknowledgement – R/M 23 Workers’ Compensation & Emergency Medical History Questionnaire – R/M 24 SCHOOL DISTRICT: DATE: SEND SUPPLIES TO: R/M 12 R-7/93
