Sedgwick Claims Kit
Oregon
P.O. Box 14779 | Lexington, KY 40512 | Toll Free: 866-738-9201 | Fax: 859-280-3275
Dear Insured:
We would like to welcome you as a policyholder of Southern Insurance Company.
Sedgwick is your Claims Administrator and we are pleased to be able to provide you
with workers’ compensation claims handling services. Please follow the below
instructions for filing a new claim and note the claim kit attachment.
Where do I report a claim?
 Phone:
 Email:
 Fax:
855-728-5277 (855-7ATLAS7) OR;
[email protected] OR:
866-383-3296
Where do I send my injured employee for medical treatment?

Website:
www.sedgwickproviders.com/AG
Sedgwick Claim Kit Attachments
•
•
•
•
•
•
•
•
Report of Job Injury (Form 801-English/Spanish)
A Guide for Workers Recently Hurt on the Job (Form 3283-English/Spanish)
Request for Release of Medical Records (Form 2476-English/Spanish)
Worker’s and Health Care Provider’s Report (Form 827-English/Spanish)
Understanding Claim Closure
Worker’s Compensation Flow Chart (Form 2235)
Atlas General First Fill Temporary Pharmacy Card
Atlas General Pharmacy Card
Need a loss run?
 Email us:
[email protected]
Have more questions?
Contact the Atlas Customer Care Team @ Sedgwick - One of our friendly Client Services
Associates will be happy to assist you.
 Phone:
866-738-9201
 Email:
[email protected]
We appreciate your business and believe that communication is critical for successful
claims administration. We encourage you to contact us if you have any questions.
www.Atlas.us.com/claims
OREGON - Welcome Letter – Southern Insurance Co. 7/2014
Insert self-insured employer and insurer name, address, phone number, and
service company, if any.
Report of Job Injury or Illness
Workers’ compensation claim
Worker
To make a claim for a work-related injury or illness, fill out the worker portion of this form and give it to your employer. If you do not intend
to file a workers’ compensation claim with the insurance company, do not sign the signature line. Your employer will give you a copy.
a.m.
Date of
Date you
Time you began work
Regularly scheduled
p.m. days off:
injury or illness:
left work:
on day of injury:
Time of injury
a.m. Time you
a.m. Check here if you have more than one
M T WT F S S
or illness:
p.m. job:
p.m. left work:
What is your illness or injury? What part of the body? Which side? (Example: Sprained right foot)
Left
Right
DEPT USE:
Emp
Ins
Occ
Nat
Part
What caused it? What were you doing? Include vehicle, machinery, or tool used. (Example: Fell 10 feet when climbing an
extension ladder carrying a 40-pound box of roofing materials)
Ev
Src
2src
Information ABOVE this line; date of death, if death occurred; and Oregon OSHA case log number must be released to an authorized worker representative upon request.
Your legal name:
Language preference:
Birthdate:
Your mailing address:
Gender: M
F
Home phone:
Social Security no. (see Form 3283):
Occupation:
Names of witnesses:
Name and phone number of health insurance company:
Were you hospitalized overnight?
Yes
Work phone:
Name and address of health care provider who treated you for the
injury or illness you are now reporting:
No
Were you treated in the emergency room?
Yes
No
By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I
authorize health care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer, self-insured
employer, claim administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior
treatment for the same conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of
HIV/AIDS records, certain drug and alcohol treatment records, and other records protected by state and federal law requires separate authorization.
Worker
Completed by
(please print):
Date:
signature:
Employer
Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company
within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.
Employer legal
business name:
Phone:
FEIN:
Client
FEIN:
If worker leasing company,
list client business name:
Address of principal place
of business (not P.O. Box):
Insurance
policy no.:
Street address from which
worker is/was supervised:
Nature of business in which worker
is/was supervised:
ZIP:
Address where
event occurred:
Was injury caused by failure of a machine or product, or by a person other than the injured worker?
Were other workers injured?
Yes
Date employer
knew of claim:
Employer
signature:
Date worker
returned to work:
440-801 (01/10/DCBS/WCD/WEB)
No
Yes
No
OSHA 300 log case no:
Worker’s
weekly wage: $
Name and title
(please print):
Date worker
hired:
If fatal, date
of death:
Date:
OSHA requirements: On-the-job fatalities and catastrophes must be reported to Oregon OSHA within eight
hours. Report any accident that results in overnight hospitalization within 24 hours to Oregon OSHA. Call
800-922-2689, 503-378-3272, or Oregon Emergency Response, 800-452-0311, on nights and weekends.
801
Insert self-insured employer and insurer name, address,
phone number, and service company, if any.
Reporte de Lesión o Enfermedad en el Trabajo
(Report of Job Injury or Illness)
Reclamación de compensación para trabajadores
(Workers’ compensation claim)
Trabajador (Worker)
Para hacer una reclamación por una lesión o enfermedad ocupacional, llene la parte de esta forma que corresponde al trabajador y entregela a
su empleador. Si usted no quiere hacer una reclamación de compensación para trabajadores con la aseguradora, no firme en la línea
dejada para su firma. Su empleador le dará una copia. (To make a claim for a work-related injury or illness, fill out the worker portion of this
form and give to your employer. If you do not intend to file a workers’ compensation claim with the insurance company, do not sign the
signature line. Your employer will give you a copy. )
Fecha de la lesión o enfermedad
(Date of injury or illness):
Fecha que dejó el trabajo
(Date you left work):
Hora que empezó a
trabajar el día de la
lesión (Time you began
a.m.
p.m.
a.m.
p.m.
Hora que dejó el
trabajo (Time you
left work):
a.m.
p.m.
DEPT USE:
Emp
scheduled days off)
work on day of
injury):
Hora en la que
ocurrió la lesión o
enfermedad (Time of
injury or illness):
Días que regularmente
no trabaja (Regularly
Ins
M T WT F S S
Marque este casillero si usted tiene
más de un trabajo. (Check here if you
have more than one job):
Occ
Nat
¿Cuál es su lesión o enfermedad? ¿En qué parte del cuerpo? ¿En qué lado? (Ejemplo: torcedura del pie derecho) What is your illness
or injury? What part of the body? Which side? (Example: sprained right foot)
Izquierdo (Left)
Derecho (Right)
Part
Ev
¿Cuál fue la causa? ¿Qué estaba haciendo? Incluya vehículo, maquinaria o herramienta usada. (Ejemplo: caí diez pies mientras subía
una escalera de extención cargando una caja de materiales que pesaba 40 libras) What caused it? What were you doing? Include vehicle,
Src
machinery, or tool used. (Example: fell ten feet when climbing an extension ladder carrying a 40-lb. box of roofing materials)
2src
Information ABOVE this line; date of death, if death occurred; and OR-OSHA case log number must be released to an authorized worker representative upon request.
Su nombre legal (Your legal name):
Idioma de preferencia (Language preference):
Su dirección postal (Your mailing address):
Número de Seguro Social SSN (Vea la Forma 3283)
(See Form 3283):
Sexo (Gender):
M
F
Teléfono del domicilio
(Home phone):
Teléfono del trabajo (Work phone):
Ocupación (Occupation):
Nombres de testigos (Names of witnesses):
Nombre y número de teléfono de la compañía aseguradora de salud (Name
and phone number of health insurance company):
Fecha de nacimiento
(Birthdate):
Nombre y dirección del proveedor médico que le trató de la lesión o
enfermedad que usted está ahora reportando (Name and address of
health care provider who treated you for the injury or illness you are now
reporting):
¿Estuvo hospitalizado como paciente durante la noche? (Were you hospitalized
overnight as an inpatient?)
Si
No
¿Recibió tratamiento en la sala de emergencia? (Were you treated in the
emergency room?)
Si
No
Con mi firma, estoy presentando una reclamación para beneficios de compensación para trabajadores. La información arriba provista es verdadera
en el mejor de mi conocimiento y creencia. Yo autorizo a proveedores médicos y a otros custodios de los récords de mi reclamación para emitir los
expedientes médicos pertinentes a la aseguradora de compensación para trabajadores, empleador asegurado por sí mismo, administrador de
reclamaciones, y al Departamento para Consumidores y Negocios de Oregon. Aviso: Los expedientes médicos pertinentes incluyen registros de
tratamiento anterior por las mismas condiciones o lesiones a la misma parte del cuerpo. Una autorización de HIPAA no es requerida (45 CFR
164.512(I)). Para emitir récords sobre el HIV/AIDS (SIDA), ciertos récords de tratamiento de drogadicción o alcoholismo, y otros récords
protegidos por la ley estatal o federal se requiere una autorización separada.
(By my signature, I am making a claim for workers’ compensation benefits. The above information is true to the best of my knowledge and belief. I authorize health
care providers and other custodians of claim records to release relevant medical records to the workers’ compensation insurer, self-insured employer, claim
administrator, and the Oregon Department of Consumer and Business Services. Notice: Relevant medical records include records of prior treatment for the same
conditions or of injuries to the same area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and
alcohol treatment records, and other records protected by state and federal law require separate authorization.)
Firma del trabajador
(Worker signature):
440-801S (1/10 tr 1/10/DCBS/WCD/WEB)
Completada por (Completed by)
Por favor escriba (please print):
Fecha
(Date):
Empleador (Employer)
Complete the rest of this form and give a copy of the form to the worker. Notify your workers’ compensation insurance company
within five days of knowledge of the claim. Even if the worker does not wish to file a claim, maintain a copy of this form.
Employer legal
business name:
If worker leasing company,
list client business name:
Address of principal place
of business (not P.O. Box):
Street address from which
worker is/was supervised:
Phone:
FEIN:
Client
FEIN:
Insurance
policy no.:
Nature of business in which worker
is/was supervised:
ZIP:
Address where
event occurred:
Was injury caused by failure of a machine or product, or by a person other than the injured worker?
Were other workers injured?
Date employer
knew of claim:
Employer
signature:
440-801S (1/10 tr 1/10/DCBS/WCD/WEB)
Yes
No
Yes
No
Date worker
returned to work:
OSHA 300 log case #:
Worker’s
Date worker
If fatal, date
weekly wage: $
hired:
of death:
Name and title
(please print):
Date:
OSHA requirements: On-the-job fatalities and catastrophes must be reported to Oregon
OSHA within eight hours. Report any accident that results in overnight hospitalization
within 24 hours to Oregon OSHA. Call 800-922-2689, 503-378-3272, or Oregon
Emergency Response 800-452-0311, on nights and weekends.
801S
A Guide for Workers Recently Hurt on the Job
How do I file a claim?
•
Notify your employer and a health care provider
of your choice about your job-related injury or
illness as soon as possible. Your employer cannot
choose your health care provider for you.
•
Ask your employer the name of its workers’
compensation insurer.
•
Complete Form 801, “Report of Job Injury or
Illness,” available from your employer and Form
827, “Worker’s and Health Care Provider’s
Report for Workers’ Compensation Claims,”
available from your health care provider.
How do I get medical treatment?
• You may receive medical treatment from the
health care provider of your choice, including:
 Authorized nurse practitioners
 Chiropractic physicians
 Medical doctors
 Naturopathic physicians
 Oral surgeons
 Osteopathic doctors
 Physician assistants
 Podiatric physicians
 Other health care providers
•
The insurance company may enroll you in a
managed care organization at any time. If it does,
you will receive more information about your
medical treatment options.
Are there limitations to my medical treatment?
•
Health care providers may be limited in how
long they may treat you and whether they may
authorize payments for time off work. Check
with your health care provider about any
limitations that may apply.
•
If your claim is denied, you may have to pay for
your medical treatment.
If I can’t work, will I receive payments for lost
wages?
•
You may be unable to work due to your jobrelated injury or illness. In order for you to receive
payments for time off work, your health care
provider must send written authorization to the
insurer.
•
Generally, you will not be paid for the first three
calendar days for time off work.
•
You may be paid for lost wages for the first three
calendar days if you are off work for 14
consecutive days or hospitalized overnight.
•
If your claim is denied within the first 14 days,
you will not be paid for any lost wages.
•
Keep your employer informed about what is going
on and cooperate with efforts to return you to a
modified- or light-duty job.
What if I have questions about my claim?
•
The insurance company or your employer should
be able to answer your questions.
•
If you have questions, concerns, or complaints,
you may also call any of the numbers below:
Ombudsman for Injured Workers:
An advocate for injured workers
Toll-free: 800-927-1271
Email: [email protected]
Workers’ Compensation Resolution Section
Toll-free: 800-452-0288
Email: [email protected]
Do I have to provide my Social Security number on Forms 801 and 827? What will it be used for? You do not need to have an
SSN to get workers’ compensation benefits. If you have an SSN, and don’t provide it, the Workers’ Compensation Division (WCD) of
the Department of Consumer and Business Services will get it from your employer, the workers’ compensation insurer, or other
sources. WCD may use your SSN for: quality assessment, correct identification and processing of claims, compliance, research, injured
worker program administration, matching data with other state agencies to measure WCD program effectiveness, injury prevention
activities, and to provide to federal agencies in the Medicare program for their use as required by federal law. The following laws
authorize WCD to get your SSN: the Privacy Act of 1974, 5 USC § 552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656;
and Oregon Administrative Rules chapter 436 (Workers’ Compensation Board Administrative Order No. 4-1967).
440-3283 (07/10/DCBS/WCD/WEB)
Una Guía para Trabajadores
Lesionados Recientemente en el Trabajo
¿Cómo presento un reclamación?
•
Lo más pronto posible notifique de su lesión o
enfermedad en el trabajo a su empleador y a un
proveedor médico de su elección. Su empleador no
puede elegir el proveedor médico para usted.
•
Pregunte a su empleador el nombre de su compañía de
compensación para trabajadores.
•
Complete la Forma 801, “Reporte de Lesión o
Enfermedad en el Trabajo” la forma puede ser
obtenida de su empleador. También llene la Forma
827, “Reporte del Trabajador y del Proveedor
Médico para Reclamaciones de Compensación para
Trabajadores” esta forma puede ser obtenida de su
proveedor médico.
Si no puedo trabajar, ¿recibiré pagos por salario
perdido?
•
Es posible que no pueda trabajar debido a su lesión o
enfermedad relacionada con el trabajo. Para que usted
pueda recibir pago por tiempo fuera del trabajo, su
proveedor médico debe enviar una autorización escrita
a la aseguradora.
•
Generalmente, usted no recibirá pagos por tiempo
perdido por los tres primeros días calendarios.
•
Es posible que reciba pago por los tres primeros días
calendarios, si usted pierde de trabajar por 14 días
consecutivos, o es hospitalizado durante un día
incluyendo la noche.
•
Si su reclamación es negada dentro de los primeros 14
días, no se le pagará por ningún salario perdido.
•
Mantenga informado a su empleador acerca del estado
de la reclamación y coopere con los esfuerzos para que
regrese a trabajar en un trabajo modificado o liviano.
¿Cómo obtengo tratamiento médico?
•
•
Usted puede recibir tratamiento médico de un
proveedor médico de su elección, incluyendo:
 Enfermeras(os) practicantes autorizadas(os)
 Médicos Quiroprácticos
 Médicos
 Médicos Naturopáticos
 Cirujanos Orales
 Médicos Osteopáticos
 Asistentes de doctor
 Médicos Podólogos
 Otros proveedores médicos
La compañía de seguros puede inscribirlo en una
organización de manejo del cuidado médico a cualquier
momento. Si la compañía lo hace, usted recibirá más
información acerca de las opciones para tratamiento
médico.
¿A quién puedo llamar si tengo preguntas acerca
de mi reclamación?
•
La compañía de seguros o su empleador pueden
responder a sus preguntas.
•
También puede llamar a los siguientes números:
Ombudsman para Trabajadores Lesionados:
Número gratuito: 1-800-927-1271
Email: [email protected]
Sección de Resolución para Trabajadores:
Número gratuito: 1-800-452-0288
Email: [email protected]
¿Existen limitaciones en mi tratamiento médico?
•
Los proveedores de cuidado médico pueden tener
limitaciones en cuanto a la duración de su
tratamiento y en cuanto a la autorización de pago
por tiempo fuera del trabajo. Pregunte a su proveedor
médico cuales son las limitaciones que pueden
aplicarse.
•
Si su reclamación es negada, es posible que usted
tenga que pagar por su tratamiento médico.
¿Debo proveer mi número de seguro social en las formas 801 y 827? ¿Para que será usado? Usted no necesita tener un número de
seguro social para recibir beneficios de compensación para trabajadores. Si usted tiene número de seguro social y no lo provee, la División de
Compensación para Trabajadores (WCD) del Departamento de Servicios para Consumidores y Negocios lo obtendrá de su empleador, de su
aseguradora de compensación para trabajadores, o de otros recursos. WCD puede usar su número de seguro social para intercambio de datos
con el Departamento de Empleo, corregir identificación y procesamiento de reclamaciones, cumplimiento, investigación, administración de
un programa para trabajadores lesionados, comparación de datos con otras agencias del estado para medir la efectividad de programas de
WCD, actividades para prevención de lesiones, y para proveerlo a agencias federales en el programa de Medicare para su uso como está
requerido por la ley federal. Las siguientes leyes autorizan a WCD a obtener su número de seguro social: the Privacy Act of 1974, 5 USC §
552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656; and Oregon Administrative Rules chapter 436 (Workers’ Compensation
Board Administrative Order No. 4-1967).
440-3283s (7/10 tr 7/10/DCBS/WCD/WEB)
Request for Release of Medical
Records for Oregon Workers’
Compensation Claim
To: Custodian of medical records
Worker information
Name:
Name:
Address:
Insurer claim number:
Date of injury:
Worker authorization/signature
By my signature, I authorize medical providers and other custodians of the claim record to release medical
records relevant to my workers’ compensation claimed conditions (see below) to the requester named below,
as provided in ORS 656.252, OAR 436-010-0240 and OAR 436-060-0017. Medical information relevant to
the claim includes a past history of complaints or treatments of a condition similar to that presented in
the claim or other conditions related to the same body part.
Worker’s signature:
Date:
Claimed conditions (Requester: List below; be specific.)
Separate authorization is required for release of the following information
•
•
The worker’s participation in federally funded drug and alcohol abuse treatment programs under Federal
Regulation 42, CFR 2.
HIV-related information protected by ORS 433.045(3).
OAR 436-010-0240 requires that medical providers respond to a request for medical records within 14
days of the date of the request. Failure to respond within 14 days to a request sent by certified mail may
subject the medical provider to penalties under OAR 436-010-0340 or 436-015-0120. This request is
being sent on
.
Please send relevant medical records by
to:
Requester’s name:
Attention:
Address:
Phone no.:
Fax no.:
440-2476
(3/12/DCBS/WCD/WEB)
Note: People who release medical information in accordance with Oregon
Administrative Rules shall bear no legal liability for such disclosure.
2476
Solicitud para Proveer Expedientes
Médicos Relevantes para
Reclamación de Compensación
para Trabajadores de Oregon
(Request for Release of Medical Records for Oregon
Workers’ Compensation Claim)
Para: Custodio de expedientes médicos
(To: Custodian of medical records)
Nombre (Name):
Dirección (Address):
Información del trabajador
(Worker information)
Nombre (Name):
Número de reclamación de la
aseguradora (Insurer claim number):
Fecha de la lesión (Date of injury):
Autorización y firma del trabajador
(Worker authorization/signature)
Con mi firma, autorizo a los proveedores médicos y demás custodios de los archivos de la reclamación para proveer los
expedientes médicos relevantes a mi(s) condición(es) reclamada(s) (abajo especificada) de compensación para
trabajadores al solicitante abajo nombrado, como está provisto en ORS 656.252, OAR 436-010-0240 y OAR 436-0600017. La información médica relevante a la reclamación incluye la historia médica anterior de quejas o tratamiento
de una condición similar a la presentada en la reclamación u otras condiciones relacionadas a la misma parte del
cuerpo.
(By my signature, I authorize medical providers and other custodians of the claim record to release medical records relevant to my
workers’ compensation claimed conditions (see below) to the requester named below, as provided in ORS 656.252, OAR 436-0100240 and OAR 436-060-0017. Medical information relevant to the claim includes a past history of complaints or treatments of a
condition similar to that presented in the claim or other conditions related to the same body part.)
Firma del Trabajador:
Fecha:
(Worker’s signature:)
(Date:)
Condiciones reclamadas (Solicitante: Listar abajo las condiciones específicas.)
(Claimed conditions (Requester: List below; be specific:))
Se requiere autorización separada para que la siguiente información sea provista
(Separate authorization is required for release of the following information)
• La participación del trabajador en programas de tratamiento de abuso de drogas y alcohol financiados federalmente
bajo la Regulación Federal 42, CFR 2. (The worker’s participation in federally funded drug and alcohol abuse treatment
programs under Federal Regulation 42, CFR 2.
• Información relacionada al HIV protegida bajo ORS 433.045(3). (HIV-related information protected by ORS 433.045(3)
440-2476s (3/12 tr 3/12/DCBS/WCD/WEB)
Page 1 of 2
OAR 436-010-0240 requiere que los proveedores médicos respondan a una solicitud para expedientes médicos
dentro de los 14 días siguientes a la fecha de la solicitud. No responder dentro de los 14 días a una solicitud enviada
por correo certificado puede resultar en multas al proveedor médico bajo OAR 436-010-0340 ó 436-015-0120. La
. (OAR 436-010-0240 requires that medical providers respond
fecha de envío de esta solicitud es
to a request for medical records within 14 days of the date of the request. Failure to respond within 14 days to a request sent by
certified mail may subject the medical provider to penalties under OAR 436-010-0340 or 436-015-0120. This request is being
sent on _______.)
a:
Por favor envíe los expedientes médicos relevantes no más tarde de:
(Please send relevant medical records by ___________ to:
Nombre del solicitante (Requester’s name):
Atención (Attention):
Dirección
(Address):
Teléfono (Phone):
Fax:
Nota: Personas que proveen información médica de acuerdo a las
Reglas Administrativas de Oregon no tendrán responsabilidad legal
alguna por proveer dicha información.
(Note: People who release medical information in accordance with Oregon
Administrative Rules shall bear no legal liability for such disclosure.)
440-2476s (3/12 tr 3/12/DCBS/WCD/WEB)
2476s
Workers’
Compensation
Division
Worker’s and Health Care Provider’s Report
for Workers’ Compensation Claims
Health care provider instructions
The worker should complete the worker section of this form for the following:
• First report of injury or disease
• Request for acceptance of a new or omitted medical condition
•
(“Omitted” refers to a condition the worker thinks should have been included among the conditions
accepted by the insurer.)
Report of aggravation of original injury
(“Aggravation” means the actual worsening of a compensable condition resulting from the original injury.)
•
Notice of change of attending physician or nurse practitioner.* This means the new provider will
be primarily responsible for treatment.
Being primarily responsible does NOT include:
• Treatment on an emergency basis
• Treatment on an “on-call” basis
• Consulting
• Specialist care (unless the specialist assumes complete control of care)
• Exams done at the request of the insurer or the Workers’ Compensation Division
*Oregon nurse practitioners, chiropractic physicians, naturopathic physicians, and physician assistants must certify
with the Workers’ Compensation Division to treat workers’ compensation patients and get paid.
After the worker has completed and signed Form 827, give the worker copies of Form 827 and Form 3283
(included with this packet) immediately.
The worker should NOT complete the worker section of this form if you choose to use it for the
following:
• Progress report
• Closing report
• Palliative care request
(Palliative care makes the worker feel better but does not cure a condition. The worker must be in the
workforce or in a vocational program to be eligible for palliative care.)
The following are not palliative care:
• Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them
• Diagnostic services
• Life-preserving treatments
• Curative care to stabilize an acute waxing and waning of symptoms
• Services to a permanently and totally disabled worker
When requesting palliative care approval from the insurer, include the following in your request:
• Who will provide the care
• Modalities ordered, including frequency and duration
• How the need for care is related to the accepted conditions
• How the care will enable the worker to continue current work or vocational training
For these reports, you have the option of filing Form 827, submitting chart notes, or submitting a report
that includes data gathered on Form 827.
Questions about name/address of insurer: 503-947-7814 or WorkCompCoverage.wcd.oregon.gov
Questions about medical issues: Contact the medical resolution team at 503-947-7606
For health care providers: www.oregonwcdoc.info
440-827 (07/14/DCBS/WCD/WEB)
827
Note to Provider:
WCD employer no.:
Policy no.:
Ask the worker to complete this form ONLY for the four filing reasons in the worker’s section; do not
have the worker complete or sign form if this is a progress report, closing report, or palliative care request.
Worker’s legal name, street address, and mailing address:
Worker or provider
OPTIONAL
Worker’s and Health Care Provider’s Report
for Workers’ Compensation Claims
Workers’
Compensation
Division
Language preference:
Male/female
Claim no. (if known):
Date of birth:
Social Security no. (see Form 3283):
Occ.
Nature
Date/time of original injury:
Occupation:
Dept. Use
Ins. no.
Last date worked:
Part
Phone:
Employer at time of original injury — name and street address:
Health insurance company name and phone:
Event
Workers’ compensation insurer’s name, address:
Source
Assoc. object
Phone:
Worker: Check reason for filing this form, answer questions (if any), and sign below.
First report of injury or disease (Do not complete or sign if you do not intend to make a claim.)
Have you injured the same body part before?
Yes
No
If yes, when:
Check here if you have more than one job.
Describe accident:
Worker
Request for acceptance of a new or omitted medical condition on an existing claim
Condition:
Notice of change of attending physician or nurse practitioner
Reason for change:
Report of aggravation of original injury (actual worsening of a compensable
condition)
By signing this form, I authorize health care providers and other custodians of claim records to release
relevant medical records. I certify that the above information is true to the best of my knowledge and
belief. (See back of form.)
X
Worker’s signature
Date
Provider: If worker initiated this report, give worker a copy immediately.
To get the name and
address of the insurer,
call the Workers’
Compensation Division’s
Employer Index
503-947-7814, or visit
online:
WorkCompCoverage.
wcd.oregon.gov
To order supplies of this
form, call 503-947-7627.
If the worker filed this report for:
•
•
•
First report of injury or illness – Send this form to the workers’ compensation insurer within 72 hours of visit.
New or omitted medical condition – Attach chart notes, including diagnostic codes. Send this form to the insurer within
five days of visit.
Change of attending physician or nurse practitioner – By signing this form, you acknowledge that you accept responsibility
for the care and treatment of the above-named worker. Send this form to the insurer within five days after the change or
the date of first treatment. Check the following, if applicable:
I request insurer to send its records.
•
Aggravation of original injury – Sign this form and send it to insurer within five days of visit.
If filing for progress report, closing report, or palliative care request, check the appropriate box below.
Provider
Progress report OR
Closing report (See instructions in Bulletin 239.)
Palliative care request – Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to
the compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided.
Date/time of first treatment:
Last date treated:
Was worker hospitalized as an inpatient?
Yes
a
Next appointment date:
Est. length of further treatment:
Has the injury or illness caused permanent impairment?
Yes
No
Impairment expected
Unknown
b
Work ability status:
c
No
If yes, name hospital:
Current diagnosis per ICD-9-CM codes:
Medically
stationary?
Regular work (job at injury) authorized start (date):
Modified work authorized from (date):
No work authorized from (date):
Yes (date):
No (anticipated date):
(Attach findings of
impairment, if any.)
through (date, if known):
through (date, if known):
Chart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any);
impairment findings (if any, and note whether temporary or permanent); physical limitations (if any); palliative care plan (specify rendering provider, modalities,
frequency, and duration); if referred to another physician, give the name and address; surgery; and history (if closing report).
Provider’s name, degree, address, and phone: (print, type, or use stamp)
X
Provider’s signature
440-827 (07/14/DCBS/WCD/WEB)
Date
— Original and one copy to insurer
— Retain copy for your records
— Copies (include Form 3283) to worker
immediately if initial claim, new or
omitted medical condition claim,
aggravation claim, or change of
attending physician or nurse
practitioner
827
Notice to worker
Claim acceptance or denial
In most instances, you will receive written notice from your employer’s insurer of the acceptance or denial of your claim within
60 days. If your employer is self-insured, your employer or the company your employer has hired to process its workers’
compensation claims will send the notice to you. If the insurer or self-insured employer denies your claim, it will explain the
reason for the denial and your rights.
Medical care
The health care provider must tell you if there are any limits to the medical services he or she may provide to you under the
Oregon workers’ compensation system.
If your claim is accepted, the insurer or self-insured employer will pay medical bills due to medical conditions the insurer accepts
in writing, including reimbursement for prescription medications, transportation, meals, lodging, and other expenses up to a
maximum established rate. You must make a written request for reimbursement and attach copies of receipts. Medical bills are
not paid before claim acceptance. Bills are not paid if your claim is denied, with some exceptions. Contact the insurer if you have
questions about who will pay your medical bills.
Payments for time lost from work
In order for you to receive payments for time lost from work, your health care provider must notify the insurer or selfinsured employer of your inability to work. After the original injury, you will not be paid for the first three calendar days you
are unable to work unless you are totally disabled for at least 14 consecutive calendar days or you are admitted to a hospital as an
inpatient within 14 days of the first onset of total disability.
You will receive a compensation check every two weeks during your recovery period as long as your health care provider verifies
your inability to work. These checks will continue until you return to work or it is determined further treatment is not expected to
improve your condition. Your time-loss benefits will be two-thirds of your gross weekly wage at the time of injury up to a
maximum set by Oregon law.
Authorization to release medical records
By signing this form, you authorize health care providers and other custodians of claim records to release relevant records to the
workers’ compensation insurer, self-insured employer, claim administrator, and the Oregon Department of Consumer and
Business Services. Relevant medical records include records of prior treatment for the same conditions or of injuries to the same
area of the body. A HIPAA authorization is not required (45 CFR 164.512(I)). Release of HIV/AIDS records, certain drug and
alcohol treatment records, and other records protected by state and federal law require separate authorization.
Caution against making false statements
Any person who knowingly makes any false statement or representation for the purpose of obtaining any benefit or payment
commits a Class A misdemeanor under ORS 656.990(1).
Palliative care
Palliative care is care that makes you feel better, but does not cure you of an unwanted condition. You must be in the workforce,
or in a vocational program, to be allowed to have palliative care.
The following are not palliative care:
• Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them
• Diagnostic services
• Life-preserving treatments
• Curative care to stabilize an acute waxing and waning of symptoms
• Services to a permanently and totally disabled worker
If you have questions about your claim that are not resolved by your employer or insurer, you may contact:
(Si Ud. tiene alguna pregunta acerca de su reclamación que no haya sido resuelta por su empleador o compañía aseguradora,
puede ponerse en contacto con):
Workers Compensation Division
(División de Compensación para Trabajadores)
P.O. Box 14480, Salem, OR 97309-0405
Salem: 503-947-7585
Toll-free: 800-452-0288
440-827 (07/14/DCBS/WCD/WEB)
Ombudsman for Injured Workers
(Ombudsman para Trabajadores Lastimados)
350 Winter Street NE, Salem, OR 97301-3878
Salem: 503-378-3351
Toll-free: 800-927-1271
A Guide for Workers Recently Hurt on the Job
How do I file a claim?
•
Notify your employer and a health care provider
of your choice about your job-related injury or
illness as soon as possible. Your employer cannot
choose your health care provider for you.
•
Ask your employer the name of its workers’
compensation insurer.
•
Complete Form 801, “Report of Job Injury or
Illness,” available from your employer and Form
827, “Worker’s and Health Care Provider’s
Report for Workers’ Compensation Claims,”
available from your health care provider.
How do I get medical treatment?
• You may receive medical treatment from the
health care provider of your choice, including:
 Authorized nurse practitioners
 Chiropractic physicians
 Medical doctors
 Naturopathic physicians
 Oral surgeons
 Osteopathic doctors
 Physician assistants
 Podiatric physicians
 Other health care providers
•
The insurance company may enroll you in a
managed care organization at any time. If it does,
you will receive more information about your
medical treatment options.
Are there limitations to my medical treatment?
•
Health care providers may be limited in how
long they may treat you and whether they may
authorize payments for time off work. Check
with your health care provider about any
limitations that may apply.
•
If your claim is denied, you may have to pay for
your medical treatment.
If I can’t work, will I receive payments for lost
wages?
•
You may be unable to work due to your jobrelated injury or illness. In order for you to receive
payments for time off work, your health care
provider must send written authorization to the
insurer.
•
Generally, you will not be paid for the first three
calendar days for time off work.
•
You may be paid for lost wages for the first three
calendar days if you are off work for 14
consecutive days or hospitalized overnight.
•
If your claim is denied within the first 14 days,
you will not be paid for any lost wages.
•
Keep your employer informed about what is going
on and cooperate with efforts to return you to a
modified- or light-duty job.
What if I have questions about my claim?
•
The insurance company or your employer should
be able to answer your questions.
•
If you have questions, concerns, or complaints,
you may also call any of the numbers below:
Ombudsman for Injured Workers:
An advocate for injured workers
Toll-free: 800-927-1271
Email: [email protected]
Workers’ Compensation Resolution Section
Toll-free: 800-452-0288
Email: [email protected]
Do I have to provide my Social Security number on Forms 801 and 827? What will it be used for? You do not need to have an
SSN to get workers’ compensation benefits. If you have an SSN, and don’t provide it, the Workers’ Compensation Division (WCD) of
the Department of Consumer and Business Services will get it from your employer, the workers’ compensation insurer, or other
sources. WCD may use your SSN for: quality assessment, correct identification and processing of claims, compliance, research, injured
worker program administration, matching data with other state agencies to measure WCD program effectiveness, injury prevention
activities, and to provide to federal agencies in the Medicare program for their use as required by federal law. The following laws
authorize WCD to get your SSN: the Privacy Act of 1974, 5 USC § 552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656;
and Oregon Administrative Rules chapter 436 (Workers’ Compensation Board Administrative Order No. 4-1967).
440-3283 (07/10/DCBS/WCD/WEB)
Reporte del Trabajador y del Proveedor Médico para Reclamaciones
de Compensación para Trabajadores, Formulario 827s
(Worker’s and Health Care Provider’s Report for Workers’ Compensation Claim, Form 827s)
Vea en el reverso de esta página las instrucciones y definiciones en español
(See back of this page for instructions and definitions in Spanish)
Instructions and definitions
Ask the worker to complete this form ONLY in the following circumstances:
• First report of injury or disease
• Request for acceptance of a new or omitted medical condition
“Omitted” refers to a condition the worker thinks should have been included among the conditions accepted by the
insurer.
•
Report of aggravation of original injury
•
Notice of change of attending physician or nurse practitioner
“Aggravation” means the actual worsening of an accepted condition resulting from the original injury.
This means the new provider will be primarily responsible for treatment. Being primarily responsible does NOT
include:
• Treatment on an emergency basis
• Treatment on an “on-call” basis
• Consulting
• Specialist care (unless the specialist assumes complete control of care)
• Exams done at the request of the insurer or the Workers’ Compensation Division
If the worker completes and signs Form 827s, give the worker copies of Form 827s and Form 3283s
(included with this packet) immediately.
Do NOT ask the worker to complete this form for the following:
• Progress report
• Closing report
• Palliative care request
Palliative care is care that makes the worker feel better but does not cure an unwanted condition. The worker must be
in the workforce or in a vocational program to be eligible for palliative care. The following are not palliative care:
• Prescriptions, prosthetics, braces, and doctors’ appointments to monitor them
• Diagnostic services
• Life-preserving treatments
• Curative care to stabilize an acute waxing and waning of symptoms
• Services to a permanently and totally disabled worker
When requesting palliative care approval from the insurer, include the following in your request:
• Who will provide the care
• Modalities ordered, including frequency and duration
• How the need for care is related to the accepted conditions
• How the care will enable the worker to continue current work or vocational training
For these reports, you have the option of filing Form 827s, submitting chart notes, or submitting a report
that includes data gathered on Form 827s.
“Regular work” under “Work ability status” means the job the worker held at the time of injury.
If you have questions about completion of Form 827s, please contact a benefit consultant at 800-452-0288.
440-827s (1/12 tr 1/12/DCBS/WCD/WEB)
827s
Reporte del Trabajador y del Proveedor Médico para Reclamaciones de
Compensación para Trabajadores, Formulario 827s
Instrucciones y definiciones
El trabajador debe completar esta forma SOLAMENTE en las siguientes circunstancias:
•
•
Primer reporte de lesión o enfermedad
Solicitud para aceptación de una condición médica nueva u omitida
“Omitida” se refiere a una condición que el trabajador piensa que debería haber sido incluida entre las
condiciones aceptadas por la aseguradora.
• Reporte de agravación de la lesión original
“Agravación” significa el empeoramiento actual de una condición médica aceptada que resulta de la lesión
original.
• Notificación de cambio de proveedor médico o enfermera(o) practicante
Esto significa que el nuevo proveedor médico será primariamente responsable por el tratamiento. El ser
primariamente responsable NO incluye:
• Tratamiento en caso de emergencia
• Tratamiento por un médico de turno (on-call)
• Consulta médica
• Tratamiento por un médico especialista (a menos de que el especialista asuma control completo del
cuidado médico)
• Exámenes médicos a pedido de la aseguradora o la División de Compensación para Trabajadores
Si es que el trabajador llena y firma el Formulario 827s, inmediatamente entregar al trabajador copias del Formulario
827s y el Formulario 3283s (incluido en este paquete).
El trabajador NO debe completar este formulario por lo siguiente:
• Reporte de progreso
• Clausura del reporte
• Cuidado paliativo
Cuidado Paliativo es un servicio médico que puede ayudar al trabajador a sentirse mejor, pero que no va a
curar una condición médica. Para calificar para cuidado paliativo usted debe estar trabajando, o en un
programa vocacional. Los siguientes no son servicios de cuidado paliativo:
• Prescripciones médicas, dispositivos prostéticos, soportes (braces), y citas médicas para control y
monitoreo
• Servicios de diagnóstico
• Tratamientos para preservar la vida
• Cuidados curativos para estabilizar un severo aumento y disminución de síntomas
• Servicios provistos a un trabajador incapacitado total y permanentemente
Para solicitar aprobación de la aseguradora para cuidado paliativo, incluya lo siguiente en su solicitud:
• Quien proveerá el cuidado paliativo
• Modalidades ordenadas, incluyendo la frecuencia y duración
• Como se relaciona la necesidad del cuidado con la condición aceptada
• Como el cuidado permitirá que el trabajador continúe con el trabajo actual o entrenamiento
vocacional
Para estos reportes, usted tiene la opción de llenar la forma 827s, presentar notas, o reportes que incluyen información
obtenida del formulario 827s.
“Trabajo regular” bajo “El estado de habilidad para trabajar” se refiere al trabajo que el trabajador estaba realizando al
momento de la lesión.
Si tiene preguntas acerca de cómo completar el Formulario 827s, póngase en contacto con un consultor de beneficios al
1-800-452-0288.
440-827s (1/12 tr 1/12/DCBS/WCD/WEB)
827s
Note to Provider:
(Worker or provider)
Trabajador o Proveedor Médico
(Nota para el Proveedor
Médico)
Reporte del Trabajador y del Proveedor Médico para Reclamaciones
de Compensación para Trabajadores
OPTIONAL
Workers’
Compensation
Division
WCD employer no.:
Policy no.:
(Worker’s and Health Care Provider’s Report for Workers’ Compensation Claims)
Ask the worker to complete this form ONLY for the four filing reasons in the worker’s section; do not
have the worker complete or sign form if this is a progress report, closing report, or palliative care request.
Nombre legal del trabajador, dirección, y dirección postal
Idioma de preferencia
(Worker’s legal name, street address, and mailing address):
(Language preference):
Masculino/
Femenino
Dept. Use
Ins. no.
Occ.
Número de Seguro Social (vea Forma 3283)
(Social Security no. (see Form 3283)):
(Male/female)
Número de reclamación (si lo sabe)
Fecha de nacimiento:
(Date of birth) (mes, día, año)
Teléfono (Phone):
Nombre y dirección del empleador al momento de la lesión original
Nature
Fecha y hora de la lesión o enfermedad inicial
(Date/time of original injury) (mes, día, año):
(Claim no. (if known)):
Ultimo día de trabajo:
(Last date worked) (mes, día, año)
Ocupación (Occupation):
Part
Nombre y teléfono de la compañía de seguro de salud (Health insurance company name and phone):
Event
Nombre y dirección de la compañía aseguradora de compensación para trabajadores (Workers’
Source
(Employer at time of original injury — name and street address):
compensation insurer’s name, address):
Assoc.
object
Teléfono (Phone):
Trabajador: Marque la casilla apropriada, conteste las preguntas (si hay algunas), y firme abajo.
Trabajador
(Worker)
Primer reporte de lesión o enfermedad ocupacional (No firme si usted no tiene la intención de registrar una
reclamación.) (First report of injury or disease (Do not complete or sign if you do not intend to make a claim.))
Marque aquí si tiene más de un empleador.
(Check here if you have more than one job.)
Se ha lesionado la misma parte del cuerpo anteriormente? (Have you injured the same body part before?)
Si
No
Si contesto sí, cuando: (If yes, when:)
Solicitud para aceptación de una condición médica nueva u omitida en una reclamación existente (Request
Describa el accidente (Describe accident):
for acceptance of a new or omitted medical condition on an existing claim)
Condición
(Condition):
Cambio de médico primario o enfermera(o) practicante (Notice of change of attending physician or nurse practitioner)
Razón para cambio (Reason for change):
Reporte de agravamiento de la lesión original (empeoramiento actual de la condición) (Report of aggravation of
original injury (actual worsening of underlying condition))
Al firmar este formulario, yo autorizo a los proveedores médicos y otros custodios de los expedientes de mi reclamación
para proveer los expedientes médicos relevantes. Yo certifico que la información arriba provista es verdadera en el
mejor de mi conocimiento y creencia. (Vea el reverso del formulario.)
(By signing this form, I authorize health care providers and other custodians of claim records to release relevant medical records. I certify
that the above information is true to the best of my knowledge and belief. (See back of form.))
X
Firma del trabajador (Worker’s signature)
Fecha (Date)
Provider: If worker initiated this report, give worker a copy immediately.
If the worker filed this report for:
•
First report of injury or illness – Send this form to the workers’ compensation insurer within 72 hours of visit.
•
New or omitted medical condition – Attach chart notes, including diagnostic codes. Send this form to the insurer
within five days of visit.
•
Change of attending physician or nurse practitioner – By signing this form, you acknowledge that you accept
responsibility for the care and treatment of the above-named worker. Send this form to the insurer within five days after
the change or the date of first treatment. Check the following, if applicable:
I request insurer to send its records.
Provider
•
Aggravation of original injury – Sign this form and send it to insurer within five days of visit.
If filing for progress report, closing report, or palliative care request, check the appropriate box below.
Progress report OR
Closing report (See instructions in Bulletin 239.)
Palliative care request – Complete remainder of form, except Section b. Attach a palliative care plan; state how care relates to the
To get the name and address
of the insurer, call the
Workers’ Compensation
Division’s Employer Index
503-947-7814, or visit online:
WorkCompCoverage.wcd.
oregon.gov
To order supplies of this
form, call 503-947-7627.
compensable condition, how care will enable worker to continue work or training, adverse effect on worker if care not provided.
a
Date/time of first treatment:
Last date treated:
Next appointment date:
Est. length of further treatment:
Has the injury or illness caused permanent impairment?
Yes
No
Impairment expected
b
c
Was worker hospitalized as an inpatient?
If yes, name hospital:
Current diagnosis per ICD-9-CM codes:
Medically
stationary?
Unknown
Yes
Yes (date):
No (anticipated date):
No
(Attach findings of
impairment, if any.)
Regular work authorized start (date):
Work ability status:
Modified work authorized from (date):
No work authorized from (date):
through (date, if known):
through (date, if known):
Chart notes: Attach chart notes to this form. The notes should specifically describe: symptoms; objective findings; type of treatment; lab/x-ray results (if any); impairment findings (if
any, and note whether temporary or permanent); physical limitations (if any); palliative care plan (specify rendering provider, modalities, frequency, and duration); if referred to another
physician, give the name and address; surgery; and history (if closing report).
Provider’s name, degree, address, and phone: (print, type, or use stamp)
X
Provider’s signature
440-827s (1/12 tr 1/12/DCBS/WCD/WEB)
Date
— Original and one copy to insurer
— Retain copy for your records
— Copies (include Form 3283s) to worker
immediately if initial claim, new or
omitted medical condition claim,
aggravation claim, or change of attending
physician or nurse practitioner
827s
Notificación al trabajador (Notice to worker)
Aceptación o Rechazo de Reclamación
En la mayoría de los casos usted recibirá notificación escrita de parte de la compañía aseguradora de su empleador aceptando o
rechazando su reclamación antes de 60 días. Si su empleador está asegurado por sí mismo, el aviso le será enviado por su empleador
o la compañía que el empleador haya contratado para procesar sus reclamaciones de compensación para trabajadores. Si su
reclamación es rechazada, se le explicará las razones del rechazo y sus derechos.
Atención médica
El proveedor médico debe avisarle si hay algún límite con los servicios médicos que él o ella pueden proveer bajo el sistema de
compensación para trabajadores de Oregon.
Si su reclamación es aceptada, la aseguradora o el empleador asegurado por sí mismo pagarán todos los costos médicos
relacionados con la lesión, incluyendo reembolsos por prescripciones médicas, transportación, comidas, alojamiento, y otros gastos
relacionados con el tratamiento de su condición hasta por el máximo establecido. Su petición para reembolso deberá hacerse por
escrito y deberá incluir copias de los recibos. Los pagos de servicios médicos no se reembolsarán antes de la aceptación de su
reclamación. Si su reclamación es rechazada no se pagarán las cuentas, con algunas excepciones. Póngase en contacto con su
aseguradora si tiene preguntas acerca de quien pagará sus gastos médicos.
Pagos por tiempo perdido de trabajo
Para que usted reciba pagos por el tiempo perdido de trabajo, su proveedor médico deberá notificar a la aseguradora o al
empleador asegurado por sí mismo de su incapacidad para trabajar. Usted no recibirá pago por los tres primeros días calendarios
que no pueda trabajar, a menos que usted esté totalmente incapacitado por 14 días calendarios consecutivos, o usted sea internado en un
hospital dentro de los 14 días a partir del principio de la incapacidad total.
Usted continuará recibiendo cheques cada dos semanas durante el período de su recuperación siempre y cuando su proveedor médico
verifique su incapacidad para trabajar. Estos cheques continuarán hasta que usted regrese al trabajo, o se determine que la continuación
del tratamiento no mejorará su condición. Sus beneficios por tiempo perdido de trabajo serán dos tercios del pago bruto de su salario
semanal al momento del accidente, hasta el máximo establecido bajo la ley de Oregon.
Autorización para compartir información sobre expedientes médicos
Al firmar este formulario, usted autoriza a los proveedores de servicios médicos y otros custodios de los expedientes de su
reclamación para que compartan información pertinente con la aseguradora de compensación para trabajadores, el empleador autoasegurado, el administrador del reclamo, y con el Departamento de Servicios para Consumidores y Negocios. Los expedientes
médicos que contienen información relevante a la reclamación incluyen su historial de tratamientos anteriores por la misma
condición o lesión de la misma parte del cuerpo. Una autorización de HIPPA no es requerida (45CFR 164.512(I)). Para compartir
récords sobre el HIV/AIDS (SIDA), ciertos tratamientos de drogadicción o alcoholismo y otros records protegidos por la ley
estatal o federal se requiere una autorización separada.
Advertencia en contra de hacer declaraciones falsas
Cualquier persona que intencionalmente hace declaraciones o representaciones falsas con el propósito de obtener cualquier beneficio o
pago, está cometiendo un delito menor Clase A bajo el Estatuto Revisado de Oregon ORS 656.990(1).
Cuidado Paliativo
Cuidado Paliativo es un servicio médico que puede ayudarle a sentirse mejor, pero que no lo va a curar de su condición médica.
Para calificar para cuidado paliativo usted debe estar trabajando, o en un programa vocacional.
Los siguientes no son considerados como cuidado paliativo:
•
•
•
•
•
Prescripciones médicas, dispositivos prostéticos, soportes (braces), y citas médicas para control y monitoreo
Servicios de diagnóstico
Tratamientos para preservar la vida;
Cuidados curativos para estabilizar un severo aumento y disminución de síntomas
Servicios provistos a un trabajador incapacitado total y permanentemente
Si tiene alguna pregunta acerca de su reclamación que su empleador o compañía aseguradora no hayan podido resolver, póngase en
contacto con:
Workers Compensation Division
(División de Compensación para Trabajadores)
P.O. Box 14480, Salem, OR 97309-0405
Salem: 503-947-7585
Toll-free: 800-452-0288
440-827s (1/12 tr 1/12/DCBS/WCD/WEB)
Ombudsman for Injured Workers
(Ombudsman para Trabajadores Lastimados)
350 Winter Street NE, Salem, OR 97301-3878
Salem: 503-378-3351
Toll-free: 800-927-1271
Una Guía para Trabajadores
Lesionados Recientemente en el Trabajo
¿Cómo presento un reclamación?
•
Lo más pronto posible notifique de su lesión o
enfermedad en el trabajo a su empleador y a un
proveedor médico de su elección. Su empleador no
puede elegir el proveedor médico para usted.
•
Pregunte a su empleador el nombre de su compañía de
compensación para trabajadores.
•
Complete la Forma 801, “Reporte de Lesión o
Enfermedad en el Trabajo” la forma puede ser
obtenida de su empleador. También llene la Forma
827, “Reporte del Trabajador y del Proveedor
Médico para Reclamaciones de Compensación para
Trabajadores” esta forma puede ser obtenida de su
proveedor médico.
¿Cómo obtengo tratamiento médico?
•
•
Usted puede recibir tratamiento médico de un
proveedor médico de su elección, incluyendo:
 Enfermeras(os) practicantes autorizadas(os)
 Médicos Quiroprácticos
 Médicos
 Médicos Naturopáticos
 Cirujanos Orales
 Médicos Osteopáticos
 Asistentes de doctor
 Médicos Podólogos
 Otros proveedores médicos
La compañía de seguros puede inscribirlo en una
organización de manejo del cuidado médico a cualquier
momento. Si la compañía lo hace, usted recibirá más
información acerca de las opciones para tratamiento
médico.
¿Existen limitaciones en mi tratamiento médico?
•
Los proveedores de cuidado médico pueden tener
limitaciones en cuanto a la duración de su
tratamiento y en cuanto a la autorización de pago
por tiempo fuera del trabajo. Pregunte a su proveedor
médico cuales son las limitaciones que pueden
aplicarse.
•
Si su reclamación es negada, es posible que usted
tenga que pagar por su tratamiento médico.
Si no puedo trabajar, ¿recibiré pagos por salario
perdido?
•
Es posible que no pueda trabajar debido a su lesión o
enfermedad relacionada con el trabajo. Para que usted
pueda recibir pago por tiempo fuera del trabajo, su
proveedor médico debe enviar una autorización escrita
a la aseguradora.
•
Generalmente, usted no recibirá pagos por tiempo
perdido por los tres primeros días calendarios.
•
Es posible que reciba pago por los tres primeros días
calendarios, si usted pierde de trabajar por 14 días
consecutivos, o es hospitalizado durante un día
incluyendo la noche.
•
Si su reclamación es negada dentro de los primeros 14
días, no se le pagará por ningún salario perdido.
•
Mantenga informado a su empleador acerca del estado
de la reclamación y coopere con los esfuerzos para que
regrese a trabajar en un trabajo modificado o liviano.
¿A quién puedo llamar si tengo preguntas acerca
de mi reclamación?
•
La compañía de seguros o su empleador pueden
responder a sus preguntas.
•
También puede llamar a los siguientes números:
Ombudsman para Trabajadores Lesionados:
Número gratuito: 1-800-927-1271
E-mail: [email protected]
Sección de Cumplimiento de Compensación para
Trabajadores:
Consultores de Beneficios
Número gratuito: 1-800-452-0288
E-mail: [email protected]
¿Debo proveer mi número de seguro social en las formas 801 y 827? ¿Para que será usado? Usted no necesita tener un número de
seguro social para recibir beneficios de compensación para trabajadores. Si usted tiene número de seguro social y no lo provee, la División de
Compensación para Trabajadores (WCD) del Departamento de Servicios para Consumidores y Negocios lo obtendrá de su empleador, de su
aseguradora de compensación para trabajadores, o de otros recursos. WCD puede usar su número de seguro social para intercambio de datos
con el Departamento de Empleo, corregir identificación y procesamiento de reclamaciones, cumplimiento, investigación, administración de
un programa para trabajadores lesionados, comparación de datos con otras agencias del estado para medir la efectividad de programas de
WCD, actividades para prevención de lesiones, y para proveerlo a agencias federales en el programa de Medicare para su uso como está
requerido por la ley federal. Las siguientes leyes autorizan a WCD a obtener su número de seguro social: the Privacy Act of 1974, 5 USC §
552a, Section (7)(a)(2)(B); Oregon Revised Statutes chapter 656; and Oregon Administrative Rules chapter 436 (Workers’ Compensation
Board Administrative Order No. 4-1967).
440-3283s (7/10 tr 7/10/DCBS/WCD/WEB)
Understanding Claim Closure and Your Rights
A guide for injured workers
What is permanent partial disability?
What is claim closure?
Permanent partial disability is the permanent loss of use or
function of any portion of the body resulting from your accepted
conditions.
When the insurer accepts your claim as disabling, you are notified
that your claim is open or active. The claim will normally continue
in that status until you recover from your on-the-job injury. Once
you have recovered or your claim otherwise qualifies, the insurer
will close your claim, which puts it in inactive status.
When can my claim be closed?
A claim is closed when one of the following happens:
UÊ Your medical records show you are medically stationary, which
means your health care provider says that your condition will
not improve with more medical treatment or the passage of
time. This may mean that, while you are not back to normal,
further treatment is not likely to help.
UÊ Your work injury is no longer the major cause of your disability
or need for treatment.
UÊ You fail to attend medical appointments.
How will I know when my claim has
been closed?
The insurer will send you a Form 1644, Notice of Closure. This
notice is important because it contains the following information:
UÊ Your work release, e.g., return to regular work or
modified work.
UÊ The dates your health care provider said you were off work or
were released to perform modified work because of your
accepted condition.
Any permanent disability resulting from the accepted condition.
UÊ The dollar value of any permanent disability resulting from the
accepted condition.
UÊ The date your condition became medically stationary or your
claim could be closed for other reasons.
UÊ The end date of your period of five-year aggravation rights. If
your condition gets worse in this five-year period, you have the
right to request your claim be reopened.
You will also receive a separate document titled Updated Notice of
Acceptance at Closure. It lists the medical conditions your insurer
has accepted and denied.
How does the insurer decide what my
EHQHÀWVDQGGLVDELOLW\DUH"
When will I receive payment if I have
permanent partial disability?
The insurer has 30 days from the mailing date of the Notice of
Closure to start making permanent disability payments.
UÊ If your permanent partial disability is valued at $6,000 or less
and you have not appealed the Notice of Closure, the insurer
will make a lump-sum (single) payment within 30 days of the
date of the Notice of Closure.
UÊ If your permanent partial disability has a value of more than
$6,000, the insurer will begin making monthly payments within
30 days of the date of the Notice of Closure, even if you have
appealed the Notice of Closure.
You may ask the insurer to pay you in a lump sum when your
permanent partial disability award is more than $6,000. However,
if you appeal the amount of your permanent partial disability, you
cannot receive a lump-sum payment until the appeal process is
finished.
If you ask for and accept a lump-sum payment of any part
of your permanent partial disability, you give up your right
to appeal the amount of the award.
Medical care after claim closure
What if I still need medical care?
After you are medically stationary, the insurer is still responsible for
some medical services as long as your current need for medical
treatment is related to the accepted conditions. The insurer will
continue to cover medical services such as prescriptions and
diagnostic and life-preserving care related to your accepted
conditions. Contact the insurer if you are not sure what medical
expenses are covered.
What if my medical condition gets worse
and I can’t work or need more treatment?
If your accepted medical condition gets worse, you may request to
reopen your claim. You must fill out Form 827, Worker’s and
Health Care Provider’s for Workers’ Compensation Claims, at
your health care provider’s office and check the box for “Report of
aggravation of original injury (actual worsening of underlying
condition).”
The insurer rates your disability and decides your benefits using
standards set by the Oregon Legislature and the Workers’
Compensation Division.
Workers’ Compensation
What if I’m unable to return to my
regular work?
Service Directory
You may be eligible for vocational assistance if you are not
released to regular work and have a permanent disability. If you
want to know if you are eligible for vocational services, you can
send a letter to the insurer asking for a vocational eligibility
evaluation. The insurer must either begin an evaluation or deny
your request. You will have appeal rights.
Who can I contact?
Reconsideration of a Notice
of Closure
Ombudsman for Injured Workers
What is reconsideration?
Reconsideration is the division’s review of your claim closure after
you or the insurer appeals it. You may ask to have anything on the
Notice of Closure reviewed. Insurers are limited to requesting
review of impairment findings that lead to an award of permanent
disability. Any part of the closure that is appealed can be upheld
or amended, and permanent partial disability can remain the
same, be increased, or be reduced.
Who can appeal the Notice of Closure?
Both you and the insurer can appeal the claim closure. You have
60 days from the mailing date on the Notice of Closure — the date
your claim closed — to request review of any part of the closure.
Should I appeal my claim closure?
The decision to appeal is up to you. You may talk to a lawyer or
the office of the Ombudsman for Injured Workers for help. Some
reasons to appeal the Notice of Closure are:
UÊ You do not think the insurer should have closed your claim
because you are not medically stationary.
UÊ You think you should have received temporary disability
benefits for a period other than what is listed on
the closure.
The insurer
The insurer’s name, address, and phone number are on the front
of the Notice of Closure.
The ombudsman will help you understand your rights, explain how
to appeal your closure, and tell you if other benefits may be
available to you.
Toll-free: 800-927-1271
503-378-3351
A lawyer
Contact a lawyer who specializes in workers’ compensation. Go
to the Oregon State Bar “Lawyer Referral Service” webpage at
http://www.osbar.org/public/ris/ris.html#referral.
Workers’ Compensation Division
Appellate Review Unit
Call for information about appealing your
claim closure.
Toll-free: 800-452-0288
503-947-7816
Benefits and Certifications Unit
Call for general information about your claim, claim closure, or
other benefits.
Toll-free: 800-452-0288
503-947-7585
E-mail: [email protected]
Website: www.wcd.oregon.gov
UÊ You think you have permanent disability and there is none
awarded on the closure.
UÊ You think you have more permanent disability than is awarded
on the closure.
How do I appeal my claim closure?
You must request reconsideration within 60 days of the date of the
Notice of Closure. You need to fill out Form 2223a, Workers
Request for Reconsideration, which is available on the Workers’
Compensation Division’s website, www.cbs.state.or.us/wcd/
policy/bulletins/forms.html. If you want the form sent to you or if
you would like to request reconsideration by phone, contact the
Appellate Review Unit at 503-947-7816, option No. 1.
OREGON
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
WCD main reception:
503-947-7810
Infoline (toll-free in Oregon):
800-452-0288
440-2876 (9/11/COM/WEB)
Workers’ Compensation Flowchart
(This is an overview. Some programs and processes are not covered.)
On-the-job injury or
occupational disease claim
:RUNHUQRWL¿HV
employer and
completes worker
section of
Form 801
Worker goes to
HCP and
completes worker
section of
Form 827
Employer reports
claim to insurer
within 5 days
HCP reports claim,
to insurer
within 3 days.
1RQGLVDEOLQJGLVDEOLQJFODVVL¿FDWLRQ
Nondisabling
means no time loss
authorized.
Disabling means
time loss authorized
or likelihood of
permanent disability.
Worker or insurer, within 30 days of Order on
Reconsideration, may request WCB hearing.*
Opinion and Order issued
Order on Reconsideration issued within 18
working days (up to 60 days longer if additional
information needed).
Denial reversed
— Return to claim
processing at “claim
accepted.” Insurer,
within 30 days, may
request WCB review.
(See “Order on
Review issued.”)
Reconsideration — Insurer, within 7 days of
claim closure, or worker, within 60 days of claim
closure, may request review by WCD.
PPD — Insurer, within 30 days of NOC,
must begin payment of award, if any.*
Worker or insurer, within 30 days,
may request WCB review.*
PWP — If worker cannot return to regular
work and has PPD, WCD issues a card
that allows worker to offer hiring
incentives to Oregon employers.
Order on Review issued
Worker or insurer, within 30 days, may appeal
to Court of Appeals (review for errors of law or
substantial evidence).*
NOC — Insurer, within 14 days, determines
extent of worker’s disability, including PPD,
if any, and closes claim.
Court of Appeals decision issued
Insurer receives knowledge that worker is
PHGLFDOO\VWDWLRQDU\RUFODLPRWKHUZLVHTXDOL¿HV
for closure.
Insurer begins TTD or TPD payments,
if authorized by attending HCP,
within 14 days of employer’s knowledge date
(EKD) and continues at 14-day intervals
unless the claim is denied.
Insurer, within 60 days of EKD,
must accept or deny claim and report
both disabling and all denied claims to WCD
within 14 days of decision.
Claim accepted —
TTD or TPD
payments, if any,
continue at 14-day
intervals for as
long as attending
SK\VLFLDQYHUL¿HV
worker’s inability
to work or until
claim closes.
440-2235 (5/11/COM)
'HQLDODI¿UPHG —
Worker, within 30
days, may request
WCB review.
(See “Order on
Review issued.”)
Vocational
assistance, if
eligible, may be
provided at any
time after claim
acceptance.
May appeal to Supreme Court
(discretionary review for errors of
law or substantial evidence).
CDA — Worker and
insurer may agree
to settle at any time,
subject to WCB
approval.
Claim denied —
Insurer issues denial
letter. TTD or TPD
payments stop.
Worker, within 60
days (up to 180 days
with cause), may
request a hearing.
See “Opinion and
Order issued.”
Workers’ Compensation Division
350 Winter St. NE
P.O. Box 14480
Salem, OR 97309-0405
www.wcd.oregon.gov
Abbreviations
801: Worker’s Report of Injury
827: First Medical Report of WC Claims
CDA: Claim Disposition Agreement
(Compromise and Release)
HCP: Health Care Provider
NOC: Notice of Closure
PPD: Permanent Partial Disability
PWP: Preferred Worker Program
TTD: Temporary Total Disability
TPD: Temporary Partial Disability
WCB: Workers’ Compensation Board
WCD: Workers’ Compensation Division
*
Some compensation is stayed (not paid) during
appeal (see ORS 656.313)
First Fill
Temporary Pharmacy Card
Making it easy to get your workers’ compensation prescriptions filled.
Employer:
Print this page immediately upon receiving notice of injury, fill in the
information below and give it to your employee.
Injured Employee:
1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys
network pharmacy.
2. Give this page to the pharmacist.
3. The pharmacist will fill your prescription at no cost.
Attention Pharmacists: Call 800.964.2531 to establish First
Fill benefit eligibility and obtain the ID# for online adjudication
of approved benefits for the injured worker.
Prescription Card
CARRIER/TPA
Sedgwick
EMPLOYER/OTHER ENTITY
Atlas General Insurance
Tmesys is the designated PBM for this patient.
INJURED WORKER NAME
Tmesys Pharmacy
Help Desk 800.964.2531
DATE OF INJURY
SOCIAL SECURITY NUMBER
Please provide directly to Pharmacist
Notice to Cardholder: This card should be presented to your pharmacy to receive
medication for your work-related injury. It is only valid within 30 days of your date of injury.
For information regarding the program or to find nearby pharmacies call 866.599.5426.
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(To create a card for your wallet, cut along outer line and fold in half.)
Pharmacist:
1. Call the Tmesys Pharmacy Help Desk at 800.964.2531.
2. Provide the information listed above.
3. The Help Desk will provide an ID number for adjudication.
Finding a Network Pharmacy
Use one of these easy methods to find a network pharmacy:
■ Visit one of the following pharmacy chains:
Duane Reade
Walmart
Walgreens
Kroger
CVS
Rite Aid
■
■
Publix
Safeway
Use our pharmacy locator online: www.pmsionline.com/pharmacy-center.
Call us: 866.599.5426
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
.
Tmesys Retail Pharmacy Network*
More than 60,000 pharmacies, including large chains and many neighborhood
independent pharmacies, meaning that your prescription can be filled at most
pharmacies nationwide.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription
Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket
Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe
Pharmacy (various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount
Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets
Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy &
Discount
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart
Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*List subject to change. This is a partial listing only.
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Tarjeta temporal
para surtir por primera vez sus recetas en farmacias
Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o
enfermedades laborales.
Empleador:
Imprima esta página inmediatamente después de recibir un aviso de lesión, complete
la información que se encuentra a continuación y entréguesela a su empleado.
Empleado lesionado:
1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con
el trabajo, diríjase a una farmacia de la red Tmesys.
2. Entréguele esta página al farmacéutico.
3. El farmacéutico le surtirá la receta sin costo alguno.
At. farmacéuticos: Llamen al 800.964.2531 a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el
número de ID para la adjudicación en línea de los beneficios aprobados
para el trabajador lesionado.
Prescription Card
COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA)
EMPLEADOR/OTRA ENTIDAD
Sedgwick
Atlas General Insurance
Tmesys es la administradora de beneficios de farmacia (PBM) asignada a
este paciente.
NOMBRE DEL EMPLEADO LESIONADO
NÚMERO DE SEGURO SOCIAL
FECHA EN QUE OCURRIÓ LA LESIÓN
Entregar directamente al farmacéutico
Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la
lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante
30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para
encontrar farmacias cercanas a usted, llame al 866.599.5426
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad)
Farmacéutico:
1. Llame al servicio de asistencia de farmacias de Tmesys al 800.964.2531.
2. Suministre la información que figura arriba.
3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación.
Cómo encontrar una farmacia de la red
Para encontrar una farmacia de la red, use uno de estos sencillos métodos:
■
Visite alguna de las siguientes cadenas de farmacias:
Walgreens
Rite Aid
Walmart
CVS
Duane Reade
Kroger
Publix
Safeway
■
Use nuestro localizador de farmacias en línea: www.pmsionline.com/pharmacy-center.
■
Llámenos: 866.599.5426
© 2013 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes
cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe Pharmacy
(various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*Lista sujeta a cambios. Ésta es sólo una lista
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
P.O. Box 152539
Tampa, FL 33684-2539
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
PERSONAL & CONFIDENTIAL
Important Insurance Claim Document Enclosed
Questions?
Prescription Delivery By Mail
In addition to providing access to your medications at a local pharmacy, Tmesys
can also deliver your medications to your home through our PMSI Mail Order
program at no cost. Using this convenient program means you will not have to
drop off or pick up your prescription or wait in line while it is being ¿lled.
For more information or to sign up, call 1.800.304.1764 or go to
www.pmsionline.com/pharmacy-center, click on Mail Order Overview.
Prescription Card
¿Necesitas ayuda en español?
Llame al 1.866.599.5426
NDC
RxBin
004261
or
CAL
or
RxPCN
Issuer (80840) 9151014609
Injury Date «DOI»
«subID»
ID#
«Patientname»
Name
Carrier/TPA «Carrier»
Envoy
002538
Envoy Acct.#
1.866.599.5426
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Note: Your use of this card is limited to those prescriptions
medically related to an injury that is considered to be covered
under the applicable state workers’ compensation law.
Attention Pharmacist: Tmesys is the designated
workers’ compensation PBM for this patient. Call Tmesys
with questions regarding transmission or rejection at:
1.800.964.2531.
Attention Cardholder: For questions regarding coverage
or to ¿nd a pharmacy call Tmesys at: 1.866.599.5426
or visit www.tmesys.com.
IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
Taking Care of
<<PATIENTNAME>>
Using the Pharmacy Card
We want to make it easy for you to obtain the medication you need to recover from your
work-related injury. Just follow these steps:
1. Activate the card by calling the toll-free number.
2. Separate the attached cards and place one in your wallet and one on your key ring.
3. Give a card to the pharmacist next time you have a new prescription or refill.
4. Your prescription will be filled at no cost.
Finding a Pharmacy
You can use any pharmacy that is part of the Tmesys network to ¿ll your prescription—and
with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding
a network pharmacy is simple! Use one of the options below:
Ŷ Visit one of the following pharmacy chains:
Walgreens
Rite Aid
Walmart
Target
Duane Reade
Kroger
Publix
Safeway
Ŷ Go to one of these nearby pharmacies:
«Pharmacy1»
«Pharmacy2»
«Pharmacy3»
Ŷ Look up a pharmacy on the website: www.tmesys.com, click on Pharmacy Locator
and choose a search option.
Ŷ Call us toll free at 1.866.599.5426.
© 2011 PMSI, Inc. All Rights Reserved. SCMSMOD

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