claims kit - care west insurance company · claims kit . content information on ... treated within...
TRANSCRIPT
Workersrsquo Compensation
Claims Kit Content Information onhellip
Posting Notices MPN Information amp Procedure Reporting an Injury Required Claim Forms
DWC-1 (Workersrsquo Compensation Claim Form amp Notice of Potential Eligibility) 5020 (Employers Report of Occupational Injury or Illness) Supervisor Forms to Complete
CONTACT INFORMATION Business Hours Monday through Friday 800am to 500pm
The claims office is closed on most nationally recognized holidays
Claim Supervisors Jenifer Snell (209) 236-7444 jsnellpegasusriskcom
Barbara Fredrickson (209) 236-7450 bfredricksonpegasusriskcom
Fax (209) 547-2839
Mail Address PO Box 5038 Modesto Ca 95352
Note When calling the Care West Claims Unit if you reach a voicemail please dial zero (0) to be transferred to a staff member who can provide immediate assistance
Status RequestFile Review E-mail CWCClaimsInfopegasusriskcom
Medical Provider Network Assistance E-mail MPNInfobillreviewscom bull Postings Phone (209) 549-3020 bull Change in Primary Treaterbull Provider Concerns
If during business hours you are unable to contact someone at the numbers noted above then please feel free to contact the Care West Insurance Company main office for assistance
at (877) 625-6566
AFTER HOURS CONTACT
1) Care Westrsquos Claims Unit at (888) 312-52462) Non-Emergency after hourrsquos calls should be handled during regular business hours listed
above
NOTE An emergency call involves loss of life limb or major catastrophic event involving severe or multiple person injuries
Posting Notices
Notice to Employees ndash Injuries Caused by Work
MPN Posting English Spanish
DWC 7 (112016)
STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Division of Workers Compensation
Notice to Employees--Injuries Caused By Work
You may be entitled to workers compensation benefits if you are injured or become ill because of your job Workers compensation
covers most work-related physical or mental injuries and illnesses An injury or illness can be caused by one event (such as hurting your
back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over)
Benefits Workers compensation benefits include
Medical Care Doctor visits hospital services physical therapy lab tests x-rays medicines medical equipment and travel costs that
are reasonably necessary to treat your injury You should never see a bill There are limits on chiropractic physical therapy and
occupational therapy visits
Temporary Disability (TD) Benefits Payments if you lose wages while recovering For most injuries TD benefits may not be
paid for more than 104 weeks within five years from the date of injury
Permanent Disability (PD) Benefits Payments if you do not recover completely and your injury causes a permanent loss of physical or
mental function that a doctor can measure
Supplemental Job Displacement Benefit A nontransferable voucher if you are injured on or after 112004 your injury causes
permanent disability and your employer does not offer you regular modified or alternative work
Death Benefits Paid to your dependents if you die from a work-related injury or illness
Naming Your Own Physician Before Injury or Illness (Predesignation) You may be able to choose the doctor who will treat you for a
job injury or illness If eligible you must tell your employer in writing the name and address of your personal physician or medical group
before you are injured You must obtain their agreement to treat you for your work injury For instructions see the written information
about workers compensation that your employer is required to give to new employees
If You Get Hurt
1 Get Medical Care If you need emergency care call 911 for help immediately from the hospital ambulance fire department or
police department If you need first aid contact your employer
2 Report Your Injury Report the injury immediately to your supervisor or to an employer representative Dont delay There are
time limits If you wait too long you may lose your right to benefits Your employer is required to provide you with a claim form
within one working day after learning about your injury Within one working day after you file a claim form your employer or
claims administrator must authorize the provision of all treatment up to ten thousand dollars consistent with the applicable
treatment guidelines for your alleged injury until the claim is accepted or rejected
3 See Your Primary Treating Physician (PTP) This is the doctor with overall responsibility for treating your injury or illness
If you predesignated your personal physician or a medical group you may see your personal physician or the medical group
after you are injured
If your employer is using a medical provider network (MPN) or a health care organization (HCO) in most cases you will be
treated within the MPN or HCO unless you predesignated a personal physician or medical group An MPN is a group of
physicians and health care providers who provide treatment to workers injured on the job You should receive information
from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claims administrator can choose the doctor who first treats
you when you are injured unless you predesignated a personal physician or medical group
4 Medical Provider Networks Your employer may be using an MPN which is a group of health care providers designated to
provide treatment to workers injured on the job If you have predesignated a personal physician or medical group prior to your
work injury then you may go there to receive treatment from your predesignated doctor If you are treating with a non-MPN
doctor for an existing injury you may be required to change to a doctor within the MPN For more information see the MPN
contact information below
MPN website ________________________________________________________________________________________________________________________
MPN Effective Date _______________________ MPN Identification number ___________________________________________
If you need help locating an MPN physician call your MPN access assistant at ___________________________________________
If you have questions about the MPN or want to file a complaint against the MPN call the MPN Contact Person at ______________
Discrimination It is illegal for your employer to punish or fire you for having a work injury or illness for filing a claim or testifying
in another persons workers compensation case If proven you may receive lost wages job reinstatement increased benefits and
costs and expenses up to limits set by the state
Questions Learn more about workers compensation by reading the information that your employer is required to give you at time of
hire If you have questions see your employer or the claims administrator (who handles workers compensation claims for your
employer)
Claims Administrator____________________________________________________ Phone ________________________________
Workersrsquo compensation insurer (Enter ldquoself-insuredrdquo if appropriate)
You can also get free information from a State Division of Workers Compensation Information (DWC) amp Assistance Officer The nearest
Information amp Assistance Officer can be found at location or
by calling toll-free (800) 736-7401 Learn more information about workersrsquo compensation online wwwdwccagov and access a useful
booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo
False claims and false denials Any person who makes or causes to be made any knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony and may
be fined and imprisoned
Your employer may not be liable for the payment of workers compensation benefits for any injury that arises from your voluntary
participation in any off-duty recreational social or athletic activity that is not part of your work-related duties
DWC 7 (112016)
ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES
Divisioacuten de Compensacioacuten de Trabajadores
Aviso a los EmpleadosmdashLesiones Causadas por el Trabajo
Es posible que usted tenga derecho a beneficios de compensacioacuten de trabajadores si usted se lesiona o se enferma a causa de su
trabajo La compensacioacuten de trabajadores cubre la mayoriacutea de las lesiones y enfermedades fiacutesicas o mentales relacionadas con el trabajo
Una lesioacuten o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caiacuteda) o por acciones
repetidas (como por ejemplo lastimarse la muntildeeca por hacer el mismo movimiento una y otra vez)
Beneficios Los beneficios de compensacioacuten de trabajadores incluyen
bull Atencioacuten Meacutedica Consultas meacutedicas servicios de hospital terapia fiacutesica anaacutelisis de laboratorio radiografiacuteas
medicinas equipo meacutedico y costos de viajar que son razonablemente necesarias para tratar su lesioacuten Usted nunca deberaacute ver un
cobro Hay liacutemites para visitas quiropraacutecticas de terapia fiacutesica y de terapia ocupacional
bull Beneficios por Incapacidad Temporal (TD) Pagos si usted pierde sueldo mientras se recupera Para la mayoriacutea de las lesiones
beneficios de TD no se pagaraacuten por maacutes de 104 semanas dentro de cinco antildeos despueacutes de la fecha de la lesioacuten
bull Beneficios por Incapacidad Permanente (PD) Pagos si usted no se recupera completamente y si su lesioacuten le causa una peacuterdida
permanente de su funcioacuten fiacutesica o mental que un meacutedico puede medir
bull Beneficio Suplementario por Desplazamiento de Trabajo Un vale no-transferible si su lesioacuten surge en o despueacutes del 1104 y su
lesioacuten le ocasiona una incapacidad permanente y su empleador no le ofrece a usted un trabajo regular modificado o alternativo
bull Beneficios por Muerte Pagados a sus dependientes si usted muere a causa de una lesioacuten o enfermedad relacionada con el
trabajo
Designacioacuten de su Propio Meacutedico Antes de una Lesioacuten o Enfermedad (Designacioacuten previa) Es posible que usted pueda elegir al
meacutedico que le atenderaacute en una lesioacuten o enfermedad relacionada con el trabajo Si elegible usted debe informarle al empleador por escrito
el nombre y la direccioacuten de su meacutedico personal o grupo meacutedico antes de que usted se lesione Usted debe de ponerse de acuerdo con su
meacutedico para que atienda la lesioacuten causada por el trabajo Para instrucciones vea la informacioacuten escrita sobre la compensacioacuten de
trabajadores que se le exige a su empleador darle a los empleados nuevos
Si Usted se Lastima
1 Obtenga Atencioacuten Meacutedica Si usted necesita atencioacuten de emergencia llame al 911 para ayuda inmediata de un hospital una
ambulancia el departamento de bomberos o departamento de policiacutea Si usted necesita primeros auxilios comuniacutequese con su
empleador
2 Reporte su Lesioacuten Reporte la lesioacuten inmediatamente a su supervisor(a) o a un representante del empleador No se demore Hay
liacutemites de tiempo Si usted espera demasiado es posible que usted pierda su derecho a beneficios Su empleador estaacute obligado
a proporcionarle un formulario de reclamo dentro de un diacutea laboral despueacutes de saber de su lesioacuten Dentro de un diacutea despueacutes de que
usted presente un formulario de reclamo el empleador o administrador de reclamos debe autorizar todo tratamiento
meacutedico hasta diez mil doacutelares de acuerdo con las pautas de tratamiento aplicables a su presunta lesioacuten hasta que el reclamo
sea aceptado o rechazado
3 Consulte al Meacutedico que le estaacute Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o
enfermedad
Si usted designoacute previamente a su meacutedico personal o grupo meacutedico usted puede consultar a su meacutedico personal o grupo
meacutedico despueacutes de lesionarse
Si su empleador estaacute utilizando una Red de Proveedores Meacutedicos (MPN) o una Organizacioacuten de Cuidado Meacutedico (HCO)
en la mayoriacutea de los casos usted seraacute tratado dentro de la MPN o la HCO a menos que usted designoacute previamente un
meacutedico personal o grupo meacutedico Una MPN es un grupo de meacutedicos y proveedores de atencioacuten meacutedica que proporcionan
tratamiento a trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si estaacute cubierto por una
HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de los casos el administrador de reclamos puede
escoger el meacutedico que lo atiende primero cuando usted se lesiona a menos que usted designoacute previamente a un meacutedico
personal o grupo meacutedico
4 Red de Proveedores Meacutedicos (MPN) Es posible que su empleador use una MPN lo cual es un grupo de proveedores de
asistencia meacutedica designados para dar tratamiento a los trabajadores lesionados en el trabajo Si usted ha hecho una designacioacuten
previa de un meacutedico personal antes de lesionarse en el trabajo entonces usted puede recibir tratamiento de su meacutedico
previamente designado Si usted estaacute recibiendo tratamiento de parte de un meacutedico que no pertenece a la MPN para una lesioacuten
existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Para maacutes informacioacuten vea la siguiente
informacioacuten de contacto de la MPN
Paacutegina web de la MPN _______________________________________________________________________________________________
Fecha de vigencia de la MPN ___________________ Nuacutemero de identificacioacuten de la MPN _______________________________________
Si usted necesita ayuda en localizar un meacutedico de una MPN llame a su asistente de acceso de la MPN al __________________________
Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN llame a la Persona de Contacto de
la MPN al _______________________________________________________________________________________________________
Discriminacioacuten Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad en el trabajo por presentar un reclamo o
por testificar en el caso de compensacioacuten de trabajadores de otra persona De ser probado usted puede recibir pagos por peacuterdida de sueldos
reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
iquestPreguntas Aprenda maacutes sobre la compensacioacuten de trabajadores leyendo la informacioacuten que se requiere que su empleador le deacute cuando
es contratado Si usted tiene preguntas vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de
compensacioacuten de trabajadores de su empleador)
Administrador de Reclamos _____________________________________________ Teleacutefono _______________________________
Asegurador del Seguro de Compensacioacuten de trabajador _______________________________ (Anote ldquoautoaseguradordquo si es apropiado)
Usted tambieacuten puede obtener informacioacuten gratuita de un Oficial de Informacioacuten y Asistencia de la Divisioacuten Estatal de Compensacioacuten de
Trabajadores El Oficial de Informacioacuten y Asistencia maacutes cercano se localiza en ________________________________________
o llamando al nuacutemero gratuito (800) 736-7401 Usted puede obtener maacutes informacioacuten sobre la compensacioacuten del trabajador en el Internet en
wwwdwccagov y acceder a una guiacutea uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo
Los reclamos falsos y rechazos falsos del reclamo Cualquier persona que haga o que ocasione que se haga una declaracioacuten o una
representacioacuten material intencionalmente falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores
es culpable de un delito grave y puede ser multado y encarcelado
Es posible que su empleador no sea responsable por el pago de beneficios de compensacioacuten de trabajadores para ninguna lesioacuten que proviene de
su participacioacuten voluntaria en cualquier actividad fuera del trabajo recreativa social o atleacutetica que no sea parte de sus deberes
laborales
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
CONTACT INFORMATION Business Hours Monday through Friday 800am to 500pm
The claims office is closed on most nationally recognized holidays
Claim Supervisors Jenifer Snell (209) 236-7444 jsnellpegasusriskcom
Barbara Fredrickson (209) 236-7450 bfredricksonpegasusriskcom
Fax (209) 547-2839
Mail Address PO Box 5038 Modesto Ca 95352
Note When calling the Care West Claims Unit if you reach a voicemail please dial zero (0) to be transferred to a staff member who can provide immediate assistance
Status RequestFile Review E-mail CWCClaimsInfopegasusriskcom
Medical Provider Network Assistance E-mail MPNInfobillreviewscom bull Postings Phone (209) 549-3020 bull Change in Primary Treaterbull Provider Concerns
If during business hours you are unable to contact someone at the numbers noted above then please feel free to contact the Care West Insurance Company main office for assistance
at (877) 625-6566
AFTER HOURS CONTACT
1) Care Westrsquos Claims Unit at (888) 312-52462) Non-Emergency after hourrsquos calls should be handled during regular business hours listed
above
NOTE An emergency call involves loss of life limb or major catastrophic event involving severe or multiple person injuries
Posting Notices
Notice to Employees ndash Injuries Caused by Work
MPN Posting English Spanish
DWC 7 (112016)
STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Division of Workers Compensation
Notice to Employees--Injuries Caused By Work
You may be entitled to workers compensation benefits if you are injured or become ill because of your job Workers compensation
covers most work-related physical or mental injuries and illnesses An injury or illness can be caused by one event (such as hurting your
back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over)
Benefits Workers compensation benefits include
Medical Care Doctor visits hospital services physical therapy lab tests x-rays medicines medical equipment and travel costs that
are reasonably necessary to treat your injury You should never see a bill There are limits on chiropractic physical therapy and
occupational therapy visits
Temporary Disability (TD) Benefits Payments if you lose wages while recovering For most injuries TD benefits may not be
paid for more than 104 weeks within five years from the date of injury
Permanent Disability (PD) Benefits Payments if you do not recover completely and your injury causes a permanent loss of physical or
mental function that a doctor can measure
Supplemental Job Displacement Benefit A nontransferable voucher if you are injured on or after 112004 your injury causes
permanent disability and your employer does not offer you regular modified or alternative work
Death Benefits Paid to your dependents if you die from a work-related injury or illness
Naming Your Own Physician Before Injury or Illness (Predesignation) You may be able to choose the doctor who will treat you for a
job injury or illness If eligible you must tell your employer in writing the name and address of your personal physician or medical group
before you are injured You must obtain their agreement to treat you for your work injury For instructions see the written information
about workers compensation that your employer is required to give to new employees
If You Get Hurt
1 Get Medical Care If you need emergency care call 911 for help immediately from the hospital ambulance fire department or
police department If you need first aid contact your employer
2 Report Your Injury Report the injury immediately to your supervisor or to an employer representative Dont delay There are
time limits If you wait too long you may lose your right to benefits Your employer is required to provide you with a claim form
within one working day after learning about your injury Within one working day after you file a claim form your employer or
claims administrator must authorize the provision of all treatment up to ten thousand dollars consistent with the applicable
treatment guidelines for your alleged injury until the claim is accepted or rejected
3 See Your Primary Treating Physician (PTP) This is the doctor with overall responsibility for treating your injury or illness
If you predesignated your personal physician or a medical group you may see your personal physician or the medical group
after you are injured
If your employer is using a medical provider network (MPN) or a health care organization (HCO) in most cases you will be
treated within the MPN or HCO unless you predesignated a personal physician or medical group An MPN is a group of
physicians and health care providers who provide treatment to workers injured on the job You should receive information
from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claims administrator can choose the doctor who first treats
you when you are injured unless you predesignated a personal physician or medical group
4 Medical Provider Networks Your employer may be using an MPN which is a group of health care providers designated to
provide treatment to workers injured on the job If you have predesignated a personal physician or medical group prior to your
work injury then you may go there to receive treatment from your predesignated doctor If you are treating with a non-MPN
doctor for an existing injury you may be required to change to a doctor within the MPN For more information see the MPN
contact information below
MPN website ________________________________________________________________________________________________________________________
MPN Effective Date _______________________ MPN Identification number ___________________________________________
If you need help locating an MPN physician call your MPN access assistant at ___________________________________________
If you have questions about the MPN or want to file a complaint against the MPN call the MPN Contact Person at ______________
Discrimination It is illegal for your employer to punish or fire you for having a work injury or illness for filing a claim or testifying
in another persons workers compensation case If proven you may receive lost wages job reinstatement increased benefits and
costs and expenses up to limits set by the state
Questions Learn more about workers compensation by reading the information that your employer is required to give you at time of
hire If you have questions see your employer or the claims administrator (who handles workers compensation claims for your
employer)
Claims Administrator____________________________________________________ Phone ________________________________
Workersrsquo compensation insurer (Enter ldquoself-insuredrdquo if appropriate)
You can also get free information from a State Division of Workers Compensation Information (DWC) amp Assistance Officer The nearest
Information amp Assistance Officer can be found at location or
by calling toll-free (800) 736-7401 Learn more information about workersrsquo compensation online wwwdwccagov and access a useful
booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo
False claims and false denials Any person who makes or causes to be made any knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony and may
be fined and imprisoned
Your employer may not be liable for the payment of workers compensation benefits for any injury that arises from your voluntary
participation in any off-duty recreational social or athletic activity that is not part of your work-related duties
DWC 7 (112016)
ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES
Divisioacuten de Compensacioacuten de Trabajadores
Aviso a los EmpleadosmdashLesiones Causadas por el Trabajo
Es posible que usted tenga derecho a beneficios de compensacioacuten de trabajadores si usted se lesiona o se enferma a causa de su
trabajo La compensacioacuten de trabajadores cubre la mayoriacutea de las lesiones y enfermedades fiacutesicas o mentales relacionadas con el trabajo
Una lesioacuten o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caiacuteda) o por acciones
repetidas (como por ejemplo lastimarse la muntildeeca por hacer el mismo movimiento una y otra vez)
Beneficios Los beneficios de compensacioacuten de trabajadores incluyen
bull Atencioacuten Meacutedica Consultas meacutedicas servicios de hospital terapia fiacutesica anaacutelisis de laboratorio radiografiacuteas
medicinas equipo meacutedico y costos de viajar que son razonablemente necesarias para tratar su lesioacuten Usted nunca deberaacute ver un
cobro Hay liacutemites para visitas quiropraacutecticas de terapia fiacutesica y de terapia ocupacional
bull Beneficios por Incapacidad Temporal (TD) Pagos si usted pierde sueldo mientras se recupera Para la mayoriacutea de las lesiones
beneficios de TD no se pagaraacuten por maacutes de 104 semanas dentro de cinco antildeos despueacutes de la fecha de la lesioacuten
bull Beneficios por Incapacidad Permanente (PD) Pagos si usted no se recupera completamente y si su lesioacuten le causa una peacuterdida
permanente de su funcioacuten fiacutesica o mental que un meacutedico puede medir
bull Beneficio Suplementario por Desplazamiento de Trabajo Un vale no-transferible si su lesioacuten surge en o despueacutes del 1104 y su
lesioacuten le ocasiona una incapacidad permanente y su empleador no le ofrece a usted un trabajo regular modificado o alternativo
bull Beneficios por Muerte Pagados a sus dependientes si usted muere a causa de una lesioacuten o enfermedad relacionada con el
trabajo
Designacioacuten de su Propio Meacutedico Antes de una Lesioacuten o Enfermedad (Designacioacuten previa) Es posible que usted pueda elegir al
meacutedico que le atenderaacute en una lesioacuten o enfermedad relacionada con el trabajo Si elegible usted debe informarle al empleador por escrito
el nombre y la direccioacuten de su meacutedico personal o grupo meacutedico antes de que usted se lesione Usted debe de ponerse de acuerdo con su
meacutedico para que atienda la lesioacuten causada por el trabajo Para instrucciones vea la informacioacuten escrita sobre la compensacioacuten de
trabajadores que se le exige a su empleador darle a los empleados nuevos
Si Usted se Lastima
1 Obtenga Atencioacuten Meacutedica Si usted necesita atencioacuten de emergencia llame al 911 para ayuda inmediata de un hospital una
ambulancia el departamento de bomberos o departamento de policiacutea Si usted necesita primeros auxilios comuniacutequese con su
empleador
2 Reporte su Lesioacuten Reporte la lesioacuten inmediatamente a su supervisor(a) o a un representante del empleador No se demore Hay
liacutemites de tiempo Si usted espera demasiado es posible que usted pierda su derecho a beneficios Su empleador estaacute obligado
a proporcionarle un formulario de reclamo dentro de un diacutea laboral despueacutes de saber de su lesioacuten Dentro de un diacutea despueacutes de que
usted presente un formulario de reclamo el empleador o administrador de reclamos debe autorizar todo tratamiento
meacutedico hasta diez mil doacutelares de acuerdo con las pautas de tratamiento aplicables a su presunta lesioacuten hasta que el reclamo
sea aceptado o rechazado
3 Consulte al Meacutedico que le estaacute Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o
enfermedad
Si usted designoacute previamente a su meacutedico personal o grupo meacutedico usted puede consultar a su meacutedico personal o grupo
meacutedico despueacutes de lesionarse
Si su empleador estaacute utilizando una Red de Proveedores Meacutedicos (MPN) o una Organizacioacuten de Cuidado Meacutedico (HCO)
en la mayoriacutea de los casos usted seraacute tratado dentro de la MPN o la HCO a menos que usted designoacute previamente un
meacutedico personal o grupo meacutedico Una MPN es un grupo de meacutedicos y proveedores de atencioacuten meacutedica que proporcionan
tratamiento a trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si estaacute cubierto por una
HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de los casos el administrador de reclamos puede
escoger el meacutedico que lo atiende primero cuando usted se lesiona a menos que usted designoacute previamente a un meacutedico
personal o grupo meacutedico
4 Red de Proveedores Meacutedicos (MPN) Es posible que su empleador use una MPN lo cual es un grupo de proveedores de
asistencia meacutedica designados para dar tratamiento a los trabajadores lesionados en el trabajo Si usted ha hecho una designacioacuten
previa de un meacutedico personal antes de lesionarse en el trabajo entonces usted puede recibir tratamiento de su meacutedico
previamente designado Si usted estaacute recibiendo tratamiento de parte de un meacutedico que no pertenece a la MPN para una lesioacuten
existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Para maacutes informacioacuten vea la siguiente
informacioacuten de contacto de la MPN
Paacutegina web de la MPN _______________________________________________________________________________________________
Fecha de vigencia de la MPN ___________________ Nuacutemero de identificacioacuten de la MPN _______________________________________
Si usted necesita ayuda en localizar un meacutedico de una MPN llame a su asistente de acceso de la MPN al __________________________
Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN llame a la Persona de Contacto de
la MPN al _______________________________________________________________________________________________________
Discriminacioacuten Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad en el trabajo por presentar un reclamo o
por testificar en el caso de compensacioacuten de trabajadores de otra persona De ser probado usted puede recibir pagos por peacuterdida de sueldos
reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
iquestPreguntas Aprenda maacutes sobre la compensacioacuten de trabajadores leyendo la informacioacuten que se requiere que su empleador le deacute cuando
es contratado Si usted tiene preguntas vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de
compensacioacuten de trabajadores de su empleador)
Administrador de Reclamos _____________________________________________ Teleacutefono _______________________________
Asegurador del Seguro de Compensacioacuten de trabajador _______________________________ (Anote ldquoautoaseguradordquo si es apropiado)
Usted tambieacuten puede obtener informacioacuten gratuita de un Oficial de Informacioacuten y Asistencia de la Divisioacuten Estatal de Compensacioacuten de
Trabajadores El Oficial de Informacioacuten y Asistencia maacutes cercano se localiza en ________________________________________
o llamando al nuacutemero gratuito (800) 736-7401 Usted puede obtener maacutes informacioacuten sobre la compensacioacuten del trabajador en el Internet en
wwwdwccagov y acceder a una guiacutea uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo
Los reclamos falsos y rechazos falsos del reclamo Cualquier persona que haga o que ocasione que se haga una declaracioacuten o una
representacioacuten material intencionalmente falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores
es culpable de un delito grave y puede ser multado y encarcelado
Es posible que su empleador no sea responsable por el pago de beneficios de compensacioacuten de trabajadores para ninguna lesioacuten que proviene de
su participacioacuten voluntaria en cualquier actividad fuera del trabajo recreativa social o atleacutetica que no sea parte de sus deberes
laborales
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Posting Notices
Notice to Employees ndash Injuries Caused by Work
MPN Posting English Spanish
DWC 7 (112016)
STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Division of Workers Compensation
Notice to Employees--Injuries Caused By Work
You may be entitled to workers compensation benefits if you are injured or become ill because of your job Workers compensation
covers most work-related physical or mental injuries and illnesses An injury or illness can be caused by one event (such as hurting your
back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over)
Benefits Workers compensation benefits include
Medical Care Doctor visits hospital services physical therapy lab tests x-rays medicines medical equipment and travel costs that
are reasonably necessary to treat your injury You should never see a bill There are limits on chiropractic physical therapy and
occupational therapy visits
Temporary Disability (TD) Benefits Payments if you lose wages while recovering For most injuries TD benefits may not be
paid for more than 104 weeks within five years from the date of injury
Permanent Disability (PD) Benefits Payments if you do not recover completely and your injury causes a permanent loss of physical or
mental function that a doctor can measure
Supplemental Job Displacement Benefit A nontransferable voucher if you are injured on or after 112004 your injury causes
permanent disability and your employer does not offer you regular modified or alternative work
Death Benefits Paid to your dependents if you die from a work-related injury or illness
Naming Your Own Physician Before Injury or Illness (Predesignation) You may be able to choose the doctor who will treat you for a
job injury or illness If eligible you must tell your employer in writing the name and address of your personal physician or medical group
before you are injured You must obtain their agreement to treat you for your work injury For instructions see the written information
about workers compensation that your employer is required to give to new employees
If You Get Hurt
1 Get Medical Care If you need emergency care call 911 for help immediately from the hospital ambulance fire department or
police department If you need first aid contact your employer
2 Report Your Injury Report the injury immediately to your supervisor or to an employer representative Dont delay There are
time limits If you wait too long you may lose your right to benefits Your employer is required to provide you with a claim form
within one working day after learning about your injury Within one working day after you file a claim form your employer or
claims administrator must authorize the provision of all treatment up to ten thousand dollars consistent with the applicable
treatment guidelines for your alleged injury until the claim is accepted or rejected
3 See Your Primary Treating Physician (PTP) This is the doctor with overall responsibility for treating your injury or illness
If you predesignated your personal physician or a medical group you may see your personal physician or the medical group
after you are injured
If your employer is using a medical provider network (MPN) or a health care organization (HCO) in most cases you will be
treated within the MPN or HCO unless you predesignated a personal physician or medical group An MPN is a group of
physicians and health care providers who provide treatment to workers injured on the job You should receive information
from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claims administrator can choose the doctor who first treats
you when you are injured unless you predesignated a personal physician or medical group
4 Medical Provider Networks Your employer may be using an MPN which is a group of health care providers designated to
provide treatment to workers injured on the job If you have predesignated a personal physician or medical group prior to your
work injury then you may go there to receive treatment from your predesignated doctor If you are treating with a non-MPN
doctor for an existing injury you may be required to change to a doctor within the MPN For more information see the MPN
contact information below
MPN website ________________________________________________________________________________________________________________________
MPN Effective Date _______________________ MPN Identification number ___________________________________________
If you need help locating an MPN physician call your MPN access assistant at ___________________________________________
If you have questions about the MPN or want to file a complaint against the MPN call the MPN Contact Person at ______________
Discrimination It is illegal for your employer to punish or fire you for having a work injury or illness for filing a claim or testifying
in another persons workers compensation case If proven you may receive lost wages job reinstatement increased benefits and
costs and expenses up to limits set by the state
Questions Learn more about workers compensation by reading the information that your employer is required to give you at time of
hire If you have questions see your employer or the claims administrator (who handles workers compensation claims for your
employer)
Claims Administrator____________________________________________________ Phone ________________________________
Workersrsquo compensation insurer (Enter ldquoself-insuredrdquo if appropriate)
You can also get free information from a State Division of Workers Compensation Information (DWC) amp Assistance Officer The nearest
Information amp Assistance Officer can be found at location or
by calling toll-free (800) 736-7401 Learn more information about workersrsquo compensation online wwwdwccagov and access a useful
booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo
False claims and false denials Any person who makes or causes to be made any knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony and may
be fined and imprisoned
Your employer may not be liable for the payment of workers compensation benefits for any injury that arises from your voluntary
participation in any off-duty recreational social or athletic activity that is not part of your work-related duties
DWC 7 (112016)
ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES
Divisioacuten de Compensacioacuten de Trabajadores
Aviso a los EmpleadosmdashLesiones Causadas por el Trabajo
Es posible que usted tenga derecho a beneficios de compensacioacuten de trabajadores si usted se lesiona o se enferma a causa de su
trabajo La compensacioacuten de trabajadores cubre la mayoriacutea de las lesiones y enfermedades fiacutesicas o mentales relacionadas con el trabajo
Una lesioacuten o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caiacuteda) o por acciones
repetidas (como por ejemplo lastimarse la muntildeeca por hacer el mismo movimiento una y otra vez)
Beneficios Los beneficios de compensacioacuten de trabajadores incluyen
bull Atencioacuten Meacutedica Consultas meacutedicas servicios de hospital terapia fiacutesica anaacutelisis de laboratorio radiografiacuteas
medicinas equipo meacutedico y costos de viajar que son razonablemente necesarias para tratar su lesioacuten Usted nunca deberaacute ver un
cobro Hay liacutemites para visitas quiropraacutecticas de terapia fiacutesica y de terapia ocupacional
bull Beneficios por Incapacidad Temporal (TD) Pagos si usted pierde sueldo mientras se recupera Para la mayoriacutea de las lesiones
beneficios de TD no se pagaraacuten por maacutes de 104 semanas dentro de cinco antildeos despueacutes de la fecha de la lesioacuten
bull Beneficios por Incapacidad Permanente (PD) Pagos si usted no se recupera completamente y si su lesioacuten le causa una peacuterdida
permanente de su funcioacuten fiacutesica o mental que un meacutedico puede medir
bull Beneficio Suplementario por Desplazamiento de Trabajo Un vale no-transferible si su lesioacuten surge en o despueacutes del 1104 y su
lesioacuten le ocasiona una incapacidad permanente y su empleador no le ofrece a usted un trabajo regular modificado o alternativo
bull Beneficios por Muerte Pagados a sus dependientes si usted muere a causa de una lesioacuten o enfermedad relacionada con el
trabajo
Designacioacuten de su Propio Meacutedico Antes de una Lesioacuten o Enfermedad (Designacioacuten previa) Es posible que usted pueda elegir al
meacutedico que le atenderaacute en una lesioacuten o enfermedad relacionada con el trabajo Si elegible usted debe informarle al empleador por escrito
el nombre y la direccioacuten de su meacutedico personal o grupo meacutedico antes de que usted se lesione Usted debe de ponerse de acuerdo con su
meacutedico para que atienda la lesioacuten causada por el trabajo Para instrucciones vea la informacioacuten escrita sobre la compensacioacuten de
trabajadores que se le exige a su empleador darle a los empleados nuevos
Si Usted se Lastima
1 Obtenga Atencioacuten Meacutedica Si usted necesita atencioacuten de emergencia llame al 911 para ayuda inmediata de un hospital una
ambulancia el departamento de bomberos o departamento de policiacutea Si usted necesita primeros auxilios comuniacutequese con su
empleador
2 Reporte su Lesioacuten Reporte la lesioacuten inmediatamente a su supervisor(a) o a un representante del empleador No se demore Hay
liacutemites de tiempo Si usted espera demasiado es posible que usted pierda su derecho a beneficios Su empleador estaacute obligado
a proporcionarle un formulario de reclamo dentro de un diacutea laboral despueacutes de saber de su lesioacuten Dentro de un diacutea despueacutes de que
usted presente un formulario de reclamo el empleador o administrador de reclamos debe autorizar todo tratamiento
meacutedico hasta diez mil doacutelares de acuerdo con las pautas de tratamiento aplicables a su presunta lesioacuten hasta que el reclamo
sea aceptado o rechazado
3 Consulte al Meacutedico que le estaacute Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o
enfermedad
Si usted designoacute previamente a su meacutedico personal o grupo meacutedico usted puede consultar a su meacutedico personal o grupo
meacutedico despueacutes de lesionarse
Si su empleador estaacute utilizando una Red de Proveedores Meacutedicos (MPN) o una Organizacioacuten de Cuidado Meacutedico (HCO)
en la mayoriacutea de los casos usted seraacute tratado dentro de la MPN o la HCO a menos que usted designoacute previamente un
meacutedico personal o grupo meacutedico Una MPN es un grupo de meacutedicos y proveedores de atencioacuten meacutedica que proporcionan
tratamiento a trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si estaacute cubierto por una
HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de los casos el administrador de reclamos puede
escoger el meacutedico que lo atiende primero cuando usted se lesiona a menos que usted designoacute previamente a un meacutedico
personal o grupo meacutedico
4 Red de Proveedores Meacutedicos (MPN) Es posible que su empleador use una MPN lo cual es un grupo de proveedores de
asistencia meacutedica designados para dar tratamiento a los trabajadores lesionados en el trabajo Si usted ha hecho una designacioacuten
previa de un meacutedico personal antes de lesionarse en el trabajo entonces usted puede recibir tratamiento de su meacutedico
previamente designado Si usted estaacute recibiendo tratamiento de parte de un meacutedico que no pertenece a la MPN para una lesioacuten
existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Para maacutes informacioacuten vea la siguiente
informacioacuten de contacto de la MPN
Paacutegina web de la MPN _______________________________________________________________________________________________
Fecha de vigencia de la MPN ___________________ Nuacutemero de identificacioacuten de la MPN _______________________________________
Si usted necesita ayuda en localizar un meacutedico de una MPN llame a su asistente de acceso de la MPN al __________________________
Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN llame a la Persona de Contacto de
la MPN al _______________________________________________________________________________________________________
Discriminacioacuten Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad en el trabajo por presentar un reclamo o
por testificar en el caso de compensacioacuten de trabajadores de otra persona De ser probado usted puede recibir pagos por peacuterdida de sueldos
reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
iquestPreguntas Aprenda maacutes sobre la compensacioacuten de trabajadores leyendo la informacioacuten que se requiere que su empleador le deacute cuando
es contratado Si usted tiene preguntas vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de
compensacioacuten de trabajadores de su empleador)
Administrador de Reclamos _____________________________________________ Teleacutefono _______________________________
Asegurador del Seguro de Compensacioacuten de trabajador _______________________________ (Anote ldquoautoaseguradordquo si es apropiado)
Usted tambieacuten puede obtener informacioacuten gratuita de un Oficial de Informacioacuten y Asistencia de la Divisioacuten Estatal de Compensacioacuten de
Trabajadores El Oficial de Informacioacuten y Asistencia maacutes cercano se localiza en ________________________________________
o llamando al nuacutemero gratuito (800) 736-7401 Usted puede obtener maacutes informacioacuten sobre la compensacioacuten del trabajador en el Internet en
wwwdwccagov y acceder a una guiacutea uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo
Los reclamos falsos y rechazos falsos del reclamo Cualquier persona que haga o que ocasione que se haga una declaracioacuten o una
representacioacuten material intencionalmente falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores
es culpable de un delito grave y puede ser multado y encarcelado
Es posible que su empleador no sea responsable por el pago de beneficios de compensacioacuten de trabajadores para ninguna lesioacuten que proviene de
su participacioacuten voluntaria en cualquier actividad fuera del trabajo recreativa social o atleacutetica que no sea parte de sus deberes
laborales
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
DWC 7 (112016)
STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS
Division of Workers Compensation
Notice to Employees--Injuries Caused By Work
You may be entitled to workers compensation benefits if you are injured or become ill because of your job Workers compensation
covers most work-related physical or mental injuries and illnesses An injury or illness can be caused by one event (such as hurting your
back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over)
Benefits Workers compensation benefits include
Medical Care Doctor visits hospital services physical therapy lab tests x-rays medicines medical equipment and travel costs that
are reasonably necessary to treat your injury You should never see a bill There are limits on chiropractic physical therapy and
occupational therapy visits
Temporary Disability (TD) Benefits Payments if you lose wages while recovering For most injuries TD benefits may not be
paid for more than 104 weeks within five years from the date of injury
Permanent Disability (PD) Benefits Payments if you do not recover completely and your injury causes a permanent loss of physical or
mental function that a doctor can measure
Supplemental Job Displacement Benefit A nontransferable voucher if you are injured on or after 112004 your injury causes
permanent disability and your employer does not offer you regular modified or alternative work
Death Benefits Paid to your dependents if you die from a work-related injury or illness
Naming Your Own Physician Before Injury or Illness (Predesignation) You may be able to choose the doctor who will treat you for a
job injury or illness If eligible you must tell your employer in writing the name and address of your personal physician or medical group
before you are injured You must obtain their agreement to treat you for your work injury For instructions see the written information
about workers compensation that your employer is required to give to new employees
If You Get Hurt
1 Get Medical Care If you need emergency care call 911 for help immediately from the hospital ambulance fire department or
police department If you need first aid contact your employer
2 Report Your Injury Report the injury immediately to your supervisor or to an employer representative Dont delay There are
time limits If you wait too long you may lose your right to benefits Your employer is required to provide you with a claim form
within one working day after learning about your injury Within one working day after you file a claim form your employer or
claims administrator must authorize the provision of all treatment up to ten thousand dollars consistent with the applicable
treatment guidelines for your alleged injury until the claim is accepted or rejected
3 See Your Primary Treating Physician (PTP) This is the doctor with overall responsibility for treating your injury or illness
If you predesignated your personal physician or a medical group you may see your personal physician or the medical group
after you are injured
If your employer is using a medical provider network (MPN) or a health care organization (HCO) in most cases you will be
treated within the MPN or HCO unless you predesignated a personal physician or medical group An MPN is a group of
physicians and health care providers who provide treatment to workers injured on the job You should receive information
from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claims administrator can choose the doctor who first treats
you when you are injured unless you predesignated a personal physician or medical group
4 Medical Provider Networks Your employer may be using an MPN which is a group of health care providers designated to
provide treatment to workers injured on the job If you have predesignated a personal physician or medical group prior to your
work injury then you may go there to receive treatment from your predesignated doctor If you are treating with a non-MPN
doctor for an existing injury you may be required to change to a doctor within the MPN For more information see the MPN
contact information below
MPN website ________________________________________________________________________________________________________________________
MPN Effective Date _______________________ MPN Identification number ___________________________________________
If you need help locating an MPN physician call your MPN access assistant at ___________________________________________
If you have questions about the MPN or want to file a complaint against the MPN call the MPN Contact Person at ______________
Discrimination It is illegal for your employer to punish or fire you for having a work injury or illness for filing a claim or testifying
in another persons workers compensation case If proven you may receive lost wages job reinstatement increased benefits and
costs and expenses up to limits set by the state
Questions Learn more about workers compensation by reading the information that your employer is required to give you at time of
hire If you have questions see your employer or the claims administrator (who handles workers compensation claims for your
employer)
Claims Administrator____________________________________________________ Phone ________________________________
Workersrsquo compensation insurer (Enter ldquoself-insuredrdquo if appropriate)
You can also get free information from a State Division of Workers Compensation Information (DWC) amp Assistance Officer The nearest
Information amp Assistance Officer can be found at location or
by calling toll-free (800) 736-7401 Learn more information about workersrsquo compensation online wwwdwccagov and access a useful
booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo
False claims and false denials Any person who makes or causes to be made any knowingly false or fraudulent material statement or
material representation for the purpose of obtaining or denying workers compensation benefits or payments is guilty of a felony and may
be fined and imprisoned
Your employer may not be liable for the payment of workers compensation benefits for any injury that arises from your voluntary
participation in any off-duty recreational social or athletic activity that is not part of your work-related duties
DWC 7 (112016)
ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES
Divisioacuten de Compensacioacuten de Trabajadores
Aviso a los EmpleadosmdashLesiones Causadas por el Trabajo
Es posible que usted tenga derecho a beneficios de compensacioacuten de trabajadores si usted se lesiona o se enferma a causa de su
trabajo La compensacioacuten de trabajadores cubre la mayoriacutea de las lesiones y enfermedades fiacutesicas o mentales relacionadas con el trabajo
Una lesioacuten o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caiacuteda) o por acciones
repetidas (como por ejemplo lastimarse la muntildeeca por hacer el mismo movimiento una y otra vez)
Beneficios Los beneficios de compensacioacuten de trabajadores incluyen
bull Atencioacuten Meacutedica Consultas meacutedicas servicios de hospital terapia fiacutesica anaacutelisis de laboratorio radiografiacuteas
medicinas equipo meacutedico y costos de viajar que son razonablemente necesarias para tratar su lesioacuten Usted nunca deberaacute ver un
cobro Hay liacutemites para visitas quiropraacutecticas de terapia fiacutesica y de terapia ocupacional
bull Beneficios por Incapacidad Temporal (TD) Pagos si usted pierde sueldo mientras se recupera Para la mayoriacutea de las lesiones
beneficios de TD no se pagaraacuten por maacutes de 104 semanas dentro de cinco antildeos despueacutes de la fecha de la lesioacuten
bull Beneficios por Incapacidad Permanente (PD) Pagos si usted no se recupera completamente y si su lesioacuten le causa una peacuterdida
permanente de su funcioacuten fiacutesica o mental que un meacutedico puede medir
bull Beneficio Suplementario por Desplazamiento de Trabajo Un vale no-transferible si su lesioacuten surge en o despueacutes del 1104 y su
lesioacuten le ocasiona una incapacidad permanente y su empleador no le ofrece a usted un trabajo regular modificado o alternativo
bull Beneficios por Muerte Pagados a sus dependientes si usted muere a causa de una lesioacuten o enfermedad relacionada con el
trabajo
Designacioacuten de su Propio Meacutedico Antes de una Lesioacuten o Enfermedad (Designacioacuten previa) Es posible que usted pueda elegir al
meacutedico que le atenderaacute en una lesioacuten o enfermedad relacionada con el trabajo Si elegible usted debe informarle al empleador por escrito
el nombre y la direccioacuten de su meacutedico personal o grupo meacutedico antes de que usted se lesione Usted debe de ponerse de acuerdo con su
meacutedico para que atienda la lesioacuten causada por el trabajo Para instrucciones vea la informacioacuten escrita sobre la compensacioacuten de
trabajadores que se le exige a su empleador darle a los empleados nuevos
Si Usted se Lastima
1 Obtenga Atencioacuten Meacutedica Si usted necesita atencioacuten de emergencia llame al 911 para ayuda inmediata de un hospital una
ambulancia el departamento de bomberos o departamento de policiacutea Si usted necesita primeros auxilios comuniacutequese con su
empleador
2 Reporte su Lesioacuten Reporte la lesioacuten inmediatamente a su supervisor(a) o a un representante del empleador No se demore Hay
liacutemites de tiempo Si usted espera demasiado es posible que usted pierda su derecho a beneficios Su empleador estaacute obligado
a proporcionarle un formulario de reclamo dentro de un diacutea laboral despueacutes de saber de su lesioacuten Dentro de un diacutea despueacutes de que
usted presente un formulario de reclamo el empleador o administrador de reclamos debe autorizar todo tratamiento
meacutedico hasta diez mil doacutelares de acuerdo con las pautas de tratamiento aplicables a su presunta lesioacuten hasta que el reclamo
sea aceptado o rechazado
3 Consulte al Meacutedico que le estaacute Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o
enfermedad
Si usted designoacute previamente a su meacutedico personal o grupo meacutedico usted puede consultar a su meacutedico personal o grupo
meacutedico despueacutes de lesionarse
Si su empleador estaacute utilizando una Red de Proveedores Meacutedicos (MPN) o una Organizacioacuten de Cuidado Meacutedico (HCO)
en la mayoriacutea de los casos usted seraacute tratado dentro de la MPN o la HCO a menos que usted designoacute previamente un
meacutedico personal o grupo meacutedico Una MPN es un grupo de meacutedicos y proveedores de atencioacuten meacutedica que proporcionan
tratamiento a trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si estaacute cubierto por una
HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de los casos el administrador de reclamos puede
escoger el meacutedico que lo atiende primero cuando usted se lesiona a menos que usted designoacute previamente a un meacutedico
personal o grupo meacutedico
4 Red de Proveedores Meacutedicos (MPN) Es posible que su empleador use una MPN lo cual es un grupo de proveedores de
asistencia meacutedica designados para dar tratamiento a los trabajadores lesionados en el trabajo Si usted ha hecho una designacioacuten
previa de un meacutedico personal antes de lesionarse en el trabajo entonces usted puede recibir tratamiento de su meacutedico
previamente designado Si usted estaacute recibiendo tratamiento de parte de un meacutedico que no pertenece a la MPN para una lesioacuten
existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Para maacutes informacioacuten vea la siguiente
informacioacuten de contacto de la MPN
Paacutegina web de la MPN _______________________________________________________________________________________________
Fecha de vigencia de la MPN ___________________ Nuacutemero de identificacioacuten de la MPN _______________________________________
Si usted necesita ayuda en localizar un meacutedico de una MPN llame a su asistente de acceso de la MPN al __________________________
Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN llame a la Persona de Contacto de
la MPN al _______________________________________________________________________________________________________
Discriminacioacuten Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad en el trabajo por presentar un reclamo o
por testificar en el caso de compensacioacuten de trabajadores de otra persona De ser probado usted puede recibir pagos por peacuterdida de sueldos
reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
iquestPreguntas Aprenda maacutes sobre la compensacioacuten de trabajadores leyendo la informacioacuten que se requiere que su empleador le deacute cuando
es contratado Si usted tiene preguntas vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de
compensacioacuten de trabajadores de su empleador)
Administrador de Reclamos _____________________________________________ Teleacutefono _______________________________
Asegurador del Seguro de Compensacioacuten de trabajador _______________________________ (Anote ldquoautoaseguradordquo si es apropiado)
Usted tambieacuten puede obtener informacioacuten gratuita de un Oficial de Informacioacuten y Asistencia de la Divisioacuten Estatal de Compensacioacuten de
Trabajadores El Oficial de Informacioacuten y Asistencia maacutes cercano se localiza en ________________________________________
o llamando al nuacutemero gratuito (800) 736-7401 Usted puede obtener maacutes informacioacuten sobre la compensacioacuten del trabajador en el Internet en
wwwdwccagov y acceder a una guiacutea uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo
Los reclamos falsos y rechazos falsos del reclamo Cualquier persona que haga o que ocasione que se haga una declaracioacuten o una
representacioacuten material intencionalmente falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores
es culpable de un delito grave y puede ser multado y encarcelado
Es posible que su empleador no sea responsable por el pago de beneficios de compensacioacuten de trabajadores para ninguna lesioacuten que proviene de
su participacioacuten voluntaria en cualquier actividad fuera del trabajo recreativa social o atleacutetica que no sea parte de sus deberes
laborales
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
DWC 7 (112016)
ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES
Divisioacuten de Compensacioacuten de Trabajadores
Aviso a los EmpleadosmdashLesiones Causadas por el Trabajo
Es posible que usted tenga derecho a beneficios de compensacioacuten de trabajadores si usted se lesiona o se enferma a causa de su
trabajo La compensacioacuten de trabajadores cubre la mayoriacutea de las lesiones y enfermedades fiacutesicas o mentales relacionadas con el trabajo
Una lesioacuten o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caiacuteda) o por acciones
repetidas (como por ejemplo lastimarse la muntildeeca por hacer el mismo movimiento una y otra vez)
Beneficios Los beneficios de compensacioacuten de trabajadores incluyen
bull Atencioacuten Meacutedica Consultas meacutedicas servicios de hospital terapia fiacutesica anaacutelisis de laboratorio radiografiacuteas
medicinas equipo meacutedico y costos de viajar que son razonablemente necesarias para tratar su lesioacuten Usted nunca deberaacute ver un
cobro Hay liacutemites para visitas quiropraacutecticas de terapia fiacutesica y de terapia ocupacional
bull Beneficios por Incapacidad Temporal (TD) Pagos si usted pierde sueldo mientras se recupera Para la mayoriacutea de las lesiones
beneficios de TD no se pagaraacuten por maacutes de 104 semanas dentro de cinco antildeos despueacutes de la fecha de la lesioacuten
bull Beneficios por Incapacidad Permanente (PD) Pagos si usted no se recupera completamente y si su lesioacuten le causa una peacuterdida
permanente de su funcioacuten fiacutesica o mental que un meacutedico puede medir
bull Beneficio Suplementario por Desplazamiento de Trabajo Un vale no-transferible si su lesioacuten surge en o despueacutes del 1104 y su
lesioacuten le ocasiona una incapacidad permanente y su empleador no le ofrece a usted un trabajo regular modificado o alternativo
bull Beneficios por Muerte Pagados a sus dependientes si usted muere a causa de una lesioacuten o enfermedad relacionada con el
trabajo
Designacioacuten de su Propio Meacutedico Antes de una Lesioacuten o Enfermedad (Designacioacuten previa) Es posible que usted pueda elegir al
meacutedico que le atenderaacute en una lesioacuten o enfermedad relacionada con el trabajo Si elegible usted debe informarle al empleador por escrito
el nombre y la direccioacuten de su meacutedico personal o grupo meacutedico antes de que usted se lesione Usted debe de ponerse de acuerdo con su
meacutedico para que atienda la lesioacuten causada por el trabajo Para instrucciones vea la informacioacuten escrita sobre la compensacioacuten de
trabajadores que se le exige a su empleador darle a los empleados nuevos
Si Usted se Lastima
1 Obtenga Atencioacuten Meacutedica Si usted necesita atencioacuten de emergencia llame al 911 para ayuda inmediata de un hospital una
ambulancia el departamento de bomberos o departamento de policiacutea Si usted necesita primeros auxilios comuniacutequese con su
empleador
2 Reporte su Lesioacuten Reporte la lesioacuten inmediatamente a su supervisor(a) o a un representante del empleador No se demore Hay
liacutemites de tiempo Si usted espera demasiado es posible que usted pierda su derecho a beneficios Su empleador estaacute obligado
a proporcionarle un formulario de reclamo dentro de un diacutea laboral despueacutes de saber de su lesioacuten Dentro de un diacutea despueacutes de que
usted presente un formulario de reclamo el empleador o administrador de reclamos debe autorizar todo tratamiento
meacutedico hasta diez mil doacutelares de acuerdo con las pautas de tratamiento aplicables a su presunta lesioacuten hasta que el reclamo
sea aceptado o rechazado
3 Consulte al Meacutedico que le estaacute Atendiendo (PTP) Este es el meacutedico con la responsabilidad total de tratar su lesioacuten o
enfermedad
Si usted designoacute previamente a su meacutedico personal o grupo meacutedico usted puede consultar a su meacutedico personal o grupo
meacutedico despueacutes de lesionarse
Si su empleador estaacute utilizando una Red de Proveedores Meacutedicos (MPN) o una Organizacioacuten de Cuidado Meacutedico (HCO)
en la mayoriacutea de los casos usted seraacute tratado dentro de la MPN o la HCO a menos que usted designoacute previamente un
meacutedico personal o grupo meacutedico Una MPN es un grupo de meacutedicos y proveedores de atencioacuten meacutedica que proporcionan
tratamiento a trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si estaacute cubierto por una
HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de los casos el administrador de reclamos puede
escoger el meacutedico que lo atiende primero cuando usted se lesiona a menos que usted designoacute previamente a un meacutedico
personal o grupo meacutedico
4 Red de Proveedores Meacutedicos (MPN) Es posible que su empleador use una MPN lo cual es un grupo de proveedores de
asistencia meacutedica designados para dar tratamiento a los trabajadores lesionados en el trabajo Si usted ha hecho una designacioacuten
previa de un meacutedico personal antes de lesionarse en el trabajo entonces usted puede recibir tratamiento de su meacutedico
previamente designado Si usted estaacute recibiendo tratamiento de parte de un meacutedico que no pertenece a la MPN para una lesioacuten
existente puede requerirse que usted se cambie a un meacutedico dentro de la MPN Para maacutes informacioacuten vea la siguiente
informacioacuten de contacto de la MPN
Paacutegina web de la MPN _______________________________________________________________________________________________
Fecha de vigencia de la MPN ___________________ Nuacutemero de identificacioacuten de la MPN _______________________________________
Si usted necesita ayuda en localizar un meacutedico de una MPN llame a su asistente de acceso de la MPN al __________________________
Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN llame a la Persona de Contacto de
la MPN al _______________________________________________________________________________________________________
Discriminacioacuten Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad en el trabajo por presentar un reclamo o
por testificar en el caso de compensacioacuten de trabajadores de otra persona De ser probado usted puede recibir pagos por peacuterdida de sueldos
reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
iquestPreguntas Aprenda maacutes sobre la compensacioacuten de trabajadores leyendo la informacioacuten que se requiere que su empleador le deacute cuando
es contratado Si usted tiene preguntas vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de
compensacioacuten de trabajadores de su empleador)
Administrador de Reclamos _____________________________________________ Teleacutefono _______________________________
Asegurador del Seguro de Compensacioacuten de trabajador _______________________________ (Anote ldquoautoaseguradordquo si es apropiado)
Usted tambieacuten puede obtener informacioacuten gratuita de un Oficial de Informacioacuten y Asistencia de la Divisioacuten Estatal de Compensacioacuten de
Trabajadores El Oficial de Informacioacuten y Asistencia maacutes cercano se localiza en ________________________________________
o llamando al nuacutemero gratuito (800) 736-7401 Usted puede obtener maacutes informacioacuten sobre la compensacioacuten del trabajador en el Internet en
wwwdwccagov y acceder a una guiacutea uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo
Los reclamos falsos y rechazos falsos del reclamo Cualquier persona que haga o que ocasione que se haga una declaracioacuten o una
representacioacuten material intencionalmente falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten de trabajadores
es culpable de un delito grave y puede ser multado y encarcelado
Es posible que su empleador no sea responsable por el pago de beneficios de compensacioacuten de trabajadores para ninguna lesioacuten que proviene de
su participacioacuten voluntaria en cualquier actividad fuera del trabajo recreativa social o atleacutetica que no sea parte de sus deberes
laborales
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Attachment F - Complete Written MPN Employee Notification
Complete Written Employee Notification Re Medical Provider Network (Title 8 California Code of Regulations section 976712)
California law requires your employer to provide and pay for medical treatment if you are injured at work Your employer Care West Insurance Company has chosen to provide this medical care by using a Workersrsquo Compensation physician network called a Medical Provider Network (MPN) This MPN is administered by Status Medical Management This notification tells you what you need to know about the MPN program and describes your rights in choosing medical care for work-related injuries and illnesses
What happens if I get injured at work
In case of an emergency you should call 911 or go to the closest emergency roomIf you are injured at work notify your employer as soon as possible Your employer will provide you with a claim form When you notify your employer that you have had a work-related injury your employer or insurer will make an initial appointment with a doctor in the MPN
What is an MPN
A Medical Provider Network (MPN) is a group of health care providers (physicians and other medical providers) used by your employer to treat workers injured on the job MPNs must allow employees to have a choice of provider(s) Each MPN must include a mix of doctors specializing in work-related injuries and doctors with expertise in general areas of medicine
What MPN is used by my employer
Your employer is using the Care West MPN with the identification number 1112 You must refer to the MPN name and the MPN identification number whenever you have questions or requests about the MPN
Who can I contact if I have questions about my MPN
The MPN Contact listed in this notification will be able to answer your questions about the use of the MPN and will address any complaints regarding the MPN The contact for your MPN is
Name MPN ContactAddress PO Box 5038 Modesto California 95352Telephone Number (888) 312-5246Email address mpninfostatusmedicalcom
General information regarding the MPN can also be found at the following website httpswwwcarewestinscom
What if I need help finding and making an appointment with a doctor
The MPNrsquos Medical Access Assistant will help you find available MPN physicians of your choice and can assist you with scheduling and confirming physician appointments The Medical Access Assistant is available to assist you Monday through Saturday from 7am-8pm (Pacific) and schedule medical appointments during doctorsrsquo normal business hours Assistance is available in English and in Spanish
Important Information about Medical Care if You Have a Work-Related Injury or Illness
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
The contact information for the Medical Access Assistant isToll Free Telephone Number (888) 312-5246Fax Number (209) 575-3130Email Address mpninfostatusmedicalcom
How do I find out which doctors are in my MPN
You can get a regional list of all MPN providers in your area by calling the MPN Contact or by going to our website at httpswwwcarewestinscom At minimum the regional list must include a list of all MPN providers within 15 miles of your workplace andor residence or a list of all MPN providers within the county where you live andor work You may choose which list you wish to receive You also have the right to obtain a list of all the MPN providers upon request
You can access the roster of all treating physicians in the MPN by going to the website at httpswwwcarewestinscom
How do I choose a provider
Your employer or the insurer for your employer will arrange the initial medical evaluation with a MPN physician After the first medical visit you may continue to be treated by that doctor or you may choose another doctor from the MPN You may continue to choose doctors within the MPN for all of your medical care for this injury
If appropriate you may choose a specialist or ask your treating doctor for a referral to a specialist Some specialists will only accept appointments with a referral from the treating doctor Such specialist might be listed as ldquoby referral onlyrdquo in your MPN directory
If you need help in finding a doctor or scheduling a medical appointment you may call the Medical Access Assistant
Can I change providers
Yes You can change providers within the MPN for any reason but the providers you choose should be appropriate to treat your injury Contact the MPN Contact or your claims adjuster if you want to change your treating physician
What standards does the MPN have to meet
The MPN has providers for the entire state of California
The MPN must give you access to a regional list of providers that includes at least three physicians in each specialty commonly used to treat work injuriesillnesses in your industry The MPN must provide access to primary treating physicians within 30 minutes or 15 miles and specialists within 60 minutes or 30 miles of where you work or live
If you live in a rural area or an area where there is a health care shortage there may be a different standard
After you have notified your employer of your injury the MPN must provide initial treatment within 3 business days If treatment with a specialist has been authorized the appointment with the specialist must be provided to you within 20 business days of your request
If you have trouble getting an appointment with a provider in the MPN contact the Medical Access Assistant
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
If there are no MPN providers in the appropriate specialty available to treat your injury within the distance and timeframe requirements then you will be allowed to seek the necessary treatment outside of the MPN
What if there are no MPN providers where I am located
If you are a current employee living in a rural area or temporarily working or living outside the MPN service area or you are a former employee permanently living outside the MPN service area the MPN or your treating doctor will give you a list of at least three physicians who can treat you The MPN may also allow you to choose your own doctor outside of the MPN network Contact your MPN Contact for assistance in finding a physician or for additional information
What if I need a specialist that is not available in the MPN
If you need to see a type of specialist that is not available in the MPN you have the right to see a specialist outside of the MPN
What if I disagree with my doctor about medical treatment
If you disagree with your doctor or wish to change your doctor for any reason you may choose another doctor within the MPN
If you disagree with either the diagnosis or treatment prescribed by your doctor you may ask for a second opinion from another doctor within the MPN If you want a second opinion you must contact the MPN contact or your claims adjuster and tell them you want a second opinion The MPN should give you at least a regional or full MPN provider list from which you can choose a second opinion doctor To get a second opinion you must choose a doctor from the MPN list and make an appointment within 60 days You must tell the MPN Contact of your appointment date and the MPN will send the doctor a copy of your medical records You can request a copy of your medical records that will be sent to the doctor
If you do not make an appointment within 60 days of receiving the regional provider list you will not be allowed to have a second or third opinion with regard to this disputed diagnosis or treatment of this treating physician
If the second-opinion doctor feels that your injury is outside of the type of injury he or she normally treats the doctors office will notify your employer or insurer and you You will get another list of MPN doctors or specialists so you can make another selection
If you disagree with the second opinion you may ask for a third opinion If you request a third opinion you will go through the same process you went through for the second opinion
Remember that if you do not make an appointment within 60 days of obtaining another MPN provider list then you will not be allowed to have a third opinion with regard to this disputed diagnosis or treatment of this treating physician
If you disagree with the third-opinion doctor you may ask for an MPN Independent Medical Review (IMR) Your employer or MPN Contact will give you information on requesting an Independent Medical Review and a form at the time you select a third-opinion physician
If either the second or third-opinion doctor or Independent Medical Reviewer agrees with your need for a treatment or test you may be allowed to receive that medical service from a provider within the MPN or if the MPN does not contain a physician who can provide the recommended treatment you may choose a physician outside the MPN within a reasonable geographic area
What if I am already being treated for a work-related injury before the MPN begins
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a ldquoTransfer of Carerdquo policy which will determine if you can continue being temporarily treated for an existing work-related injury by a physician outside of the MPN before your care is transferred into the MPN
If your current doctor is not or does not become a member of the MPN then you may be required to see a MPN physician However if you have properly predesignated a primary treating physician you cannot be transferred into the MPN (If you have questions about predesignation ask your supervisor)
If your employer decides to transfer you into the MPN you and your primary treating physician must receive a letter notifying you of the transfer
If you meet certain conditions you may qualify to continue treating with a non-MPN physician for up to a year before you are transferred into the MPN The qualifying conditions to postpone the transfer of your care into the MPN are set forth in the box below
You can disagree with your employerrsquos decision to transfer your care into the MPN If you donrsquot want to be transferred into the MPN ask your primary treating physician for a medical report on whether you have one of the four conditions stated above to qualify for a postponement of your transfer into the MPN
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher report on your condition If your primary treating physician does not give you the report within 20 days of your request the employer can transfer your care into the MPN and you will be required to use an MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the transfer of your care If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Transfer of Care policy for more details on the dispute resolution process
For a copy of the Transfer of Care policy in English or Spanish ask your MPN Contact
What if I am being treated by a MPN doctor who decides to leave the MPN
Can I Continue Being Treated By My Doctor
You may qualify for continuing treatment with your non-MPN provider (through transfer of care or continuity of care) for up to a year if your injury or illness meets any of the following conditions
(Acute) The treatment for your injury or illness will be completed in less than 90 days(Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment You may be allowed to be treated by your current treating doctor for up to one year until a safe transfer of care can be made(Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less(Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date or the termination of contract date between the MPN and your doctor
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Your employer or insurer has a written ldquoContinuity of Carerdquo policy that will determine whether you can temporarily continue treatment for an existing work injury with your doctor if your doctor is no longer participating in the MPN
If your employer decides that you do not qualify to continue your care with the non-MPN provider you and your primary treating physician must receive a letter notifying you of this decision
If you meet certain conditions you may qualify to continue treating with this doctor for up to a year before you must choose a MPN physician These conditions are set forth in the ldquoCan I Continue Being Treated By My Doctorrdquo box above
You can disagree with your employerrsquos decision to deny you Continuity of Care with the terminated MPN provider If you want to continue treating with the terminated doctor ask your primary treating physician for a medical report on whether you have one of the four conditions stated in the box above to see if you qualify to continue treating with your current doctor temporarily
Your primary treating physician has 20 days from the date of your request to give you a copy of hisher medical report on your condition If your primary treating physician does not give you the report within 20 days of your request your employerrsquos decision to deny you Continuity of Care with your doctor who is no longer participating in the MPN will apply and you will be required to choose a MPN physician
You will need to give a copy of the report to your employer if you wish to postpone the selection of aMPN doctor treatment If you or your employer disagrees with your doctorrsquos report on your condition you or your employer can dispute it See the complete Continuity of Care policy for more details on the dispute resolution process
For a copy of the Continuity of Care policy in English or Spanish ask your MPN Contact
What if I have questions or need help
MPN Contact You may always contact the MPN Contact if you have questions about the use of the MPN and to address any complaints regarding the MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Division of Workersrsquo Compensation (DWC) If you have concerns complaints or questions regarding the MPN the notification process or your medical treatment after a work-related injury or illness you can call the DWCrsquos Information and Assistance office at 1-800-736-7401 You can also go to the DWCrsquos website at wwwdircagovdwc and click on ldquomedical provider networksrdquo for more information about MPNs
Independent Medical Review If you have questions about the MPN Independent Medical Review process contact the Division of Workersrsquo Compensationrsquos Medical Unit at
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Keep this information in case you have a work-related injury or illness
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Completa Notificacioacuten Inicial Escrita del Empleado sobre la Red de Proveedores Meacutedicos(Tiacutetulo 8 Coacutedigo de Regulaciones de California seccioacuten 976712)
La ley de California requiere que su empleador le proporcione y pague el tratamiento meacutedico si se lesiona en el trabajo Su empleador Care West Insurance Company ha elegido a proporcionarle este cuidado meacutedico utilizando una red de meacutedicos de Compensacioacuten de Trabajadores llamada Red deProveedores Meacutedicos o MPN (Medical Provider Network) Esta MPN estaacute administrada por Status Medical Management Esta notificacioacuten le informaraacute lo que necesita saber sobre el programa de la MPN y le describiraacute sus derechos en elegir cuidado meacutedico para sus lesiones o enfermedades de trabajo
iquestQueacute pasa si me lastimo en el trabajo
En caso de emergencia debe llamar al 911 o ir a la sala de emergencias maacutes cercanaSi se lesiona en el trabajo notifique a su empleador lo maacutes pronto posible Su empleador le proporcionaraacute un formulario de reclamo Cuando le notifique a su empleador que ha sufrido una lesioacuten de trabajo su empleador haraacute la cita inicial con el meacutedico de la MPN
iquestQueacute es una MPN
Una Red de Proveedores Meacutedicos o MPN es un grupo de proveedores de asistencia medica usados por su empleador (meacutedicos y otros proveedores meacutedicos) utilizados por su empleador para atender a trabajadores que se lesionan en el trabajo Cada MPN debe incluir una combinacioacuten de meacutedicos que se especializan en lesiones de trabajo y meacutedicos expertos en areas de meacutedicina general
Que es una MPN usado por mi empleador
Su empleador esta usando Care West MPN con numero de identificacion 1112 Usted debe referirse al nombre y numero de identificacion de la MPN cuando tenga preguntas o peticiones acerca de la MPN
iquestCoacutemo puedo averiguar cuales meacutedicos pertenecen a mi MPN
El Contacto de la MPN enlistado en esta notificacion podra contester sus preguntas sobre como usar la MPN y resolvera cualquier queja respect a la MPN The contact for your MPN is
Nombre MPN ContactDireccion PO Box 5038 Modesto California 95352Numero telefonico (888) 312-5246Correo electronico mpninfostatusmedicalcom
Informacion General respect a la MPN tambien puede ser encontrada en la siguente pagina de la red httpswwwcarewestinscom
Que si necesito ayuda para encontrar un medico
El Asistente de Acceso Medico de la MPN le ayudara a encontrar un medico de la MPN disponible de su eleccion y puede asistirle en hacer y confirmar una cita medica El Asistente de Acceso Medico esta disponible de Lunes a Sabado de 7am- 8pm(Pacifico) y a programar citas medicas durante las horas de las oficinas medicas La asitencia esta disponible en Ingles y EspantildeolLa informacion de contacto para el Asistente de Acceso Medico es
Numero de telefono gratuito (888) 312-5246Numero de Fax (209) 575-3130
Informacioacuten Importante sobre Cuidado Meacutedico si tiene una Lesioacuten o Enfermedad de Trabajo
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
a un meacutedico de la MPN Sin embargo si usted apropiadamente ha designado previamente un meacutedico para atenderlo usted no puede ser transferido a la MPN (Si tiene preguntas acerca de la designacioacuten previa preguntele a su supervisor)
Si su empleador decide tranferirlo a la MPN usted y su meacutedico que lo estaacute atendiendo deben recibir una carta notificandoles de la tranferencia
Si usted llena ciertos requisitos pueda que califique a continuar ser atendido por un meacutedico fuera de la MPN hasta por un antildeo antes de que sea transferido a la MPN Los requisitos para posponer la tranferencia de su cuidado a la MPN estaacuten expuestos en la caja debajo
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre transferir su cuidado a la MPN Si no quiere ser transferido a la MPN pidale a su meacutedico que lo estaacute atendiendo por un informe meacutedico que indique si tiene una de las cuatro condiciones indicadas arriba para poder posponer su transferencia a la MPN
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten el empleador podraacute transferir su cuidado a la MPN y estaraacute obligado a utilizar un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la transferencia de su cuidado Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de Transferencia de Cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan entero sobre la Transferencia de Cuidado en ingleacutes o espantildeol preguacutentele a su contacto de la MPN
iquestQueacute tal si estoy bajo tratamiento con un meacutedico de la MPN que decide dejar la MPN
iquestPuedo Continuar Ser Tratado Por Mi Meacutedico
Usted puede calificar para tratamiento continuo con su proveedor que no estaacute dentro de la MPN (por transferencia de cuidado o continuidad de cuidado) hasta por un antildeo si su lesioacuten o enfermedad llena cualquiera de las siguientes condiciones
(Agudo) El tratamiento para su lesioacuten o enfermedad seraacute completado en menos de 90 diacuteas(Grave o croacutenico) Su lesioacuten o enfermedad es una que es grave y continua por lo menos 90 diacuteas sin una cura total o empeora y requiere de tratamiento continuo Se le podraacute permitir ser tratado por su meacutedico actual hasta por un antildeo hasta que una transferencia de cuidado segura pueda ser hecha(Terminal) Tiene una enfermedad incurable o condicioacuten irreversible que probablemente cause la muerte dentro de un antildeo o menos(Cirugiacutea pendiente) Ya tiene una cirugiacutea u otro procedimiento que ha sido autorizado por su empleador o compantildeiacutea de seguros y que se realizaraacute dentro de 180 diacuteas a partir de la fecha efectiva de la MPN o la fecha de la terminacioacuten del contrato entre la MPN y su meacutedico
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Correo Electronico mpninfostatusmedicalcom
Como averiguo cuales provedores medicos son parte de la MPN
Usted puede obtener una lista regional de todos los provedores de la MPN en su area con el contacto or visitando la paging de la Redhttpswwwcarewestinscom Al minimo la lista regional deve de incluir una lista de todos los provedores de la MPN una distancia de 15 millas de donde usted trabaja o recide o una lilsta de todos los provedores de la MPN en el condado donde usted reside o trabaja Usted puede elegir cual lista desea recibir Usted tambien tiene el deredho de obtenre una lista de todos los provedores de la MPN si lo require
Usted puede tener acceso a la lista de todos los medicos tratantes en la MPN visitando el sitio de la red httpswwwcarewestinscom
iquestCoacutemo escojo un proveedor
Su empleador o la aseguradora de su empleador areglara la evaluacion medical inicial con un medico de la MPN Despueacutes de la primera visita meacutedica puede continuar ser atendido por este meacutedico o puede elegir otro meacutedico dentro de la MPN Puede continuar eligiendo meacutedicos de la MPN para todo su cuidado meacutedico para esta lesioacuten Si es apropiado puede escoger un especialista o puede pedirle al meacutedico que lo estaacute atendiendo que lo refiera a un especialista Si necesita ayuda en eligir un meacutedico puede llamarle al contacto de la MPN arriba descrito Algunos especialistas solo aceptaran citas con una referencia de el medico tratante Dicho especialista puede ser enlistado como ldquopor referencia solamenterdquo en el directorio de la MPN
Si necesita ayuda para encontrar un doctor o hacer una cita medica puede llamar al Asistente de Acceso Medico
iquestPuedo cambiar de proveedor
Siacute Usted puede cambiar de proveedores dentro de la MPN por cualquier razoacuten pero los proveedores que elija deben ser apropiados para tratar su lesioacuten Contacte al contacto de la MPN o a su ajustador de reclamos si desea cambiar su medico tratante
iquestQueacute requisitos debe tener la MPN
La MPN tiene proveedores en los siguentes para todo el estado de California
La MPN tiene que proporcionarle acceso a una lista regional de proveedores que incluya por lo menos tres meacutedicos en cada especialidad usualmente utilizada para tratar lesionesenfermedades en su industria La MPN debe proporcionarle acceso a meacutedicos primariosMedicos que tratan dentro de 30minutos o 15 millas y especialistas dentro de 60minutos o 30millasde distancia de donde usted vive o trabaja Si usted vive en una aacuterea rural o en una aacuterea donde hay un cuidado medico escaso puede ser un estaacutendar diferente
Despues de haber notificado a su emleador sobre su lesion la MPN debe proporcionar tratamiento incial dentro de 3 dias Si el tratamiento con un especialista ha sido autorizado la cita con el especialista debe de ser proveida dentro de 20 dias de negocio desde su pedido
Si tiene dificultad para conseguir una cita con un provedor de la MPN contacte al Asistente de Acceso Medico
Si no hay provedores de la MPN en la especialildad apropiada disponibles a tartar su lesion dentro de la distancia y tiempos requeridos entonces se le permitira buscar el tratamiento necesario fuera de la MPN
iquestQueacute tal si no hay proveedores de la MPN donde estoy localizado
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Si estaacute temporalmente trabajando o viviendo fuera de la area de servicio de la MPN o en una area rural la MPN o el meacutedico que lo estaacute atendiendo le daraacute una lista de por lo menos tres meacutedicos que lo puedan atender La MPN tambieacuten puede permitirle elegir su propio meacutedico fuera de la red de la MPN Poacutengase en contacto con su contacto de la MPN para asistencia en encontrar un meacutedico o para informacioacuten adicional
iquestQueacute tal si necesito un especialista que no estaacute dentro de la MPN
Si necesita ver un especialista que no estaacute disponible dentro de la MPN usted tiene derecho a ver un especialista fuera de la MPN
iquestQueacute tal si no estoy de acuerdo con mi meacutedico sobre tratamiento meacutedico
Si usted no estaacute de acuerdo con su meacutedico o desea cambiar de meacutedico por cualquier razoacuten usted puede escoger otro meacutedico dentro de la MPN
Si usted no estaacute de acuerdo con el diagnosis o tratamiento recetado por su meacutedico usted puede pedir una segunda opinioacuten de un meacutedico dentro de la MPN Si quiere una segunda opinioacuten debe ponerse en contacto con la MPN contacte a su ajustador de reclamos y digale que quiere una segunda opinioacuten La persona de contacto aseguraraacute que por lo menos tenga una lista regional o completa de proveedores de la MPN para elegirlo Para obtener una segunda opinioacuten debe elegir un meacutedico dentro de la lista de la MPN y hacer una cita dentro de 60 diacuteas Usted debe decirle al contacto de la MPN la fecha de su cita y el contacto de la MPN le mandaraacute al meacutedico una copia de su expediente meacutedico Usted puede pedir una copia de su expediente meacutedico que se le enviaraacute al meacutedico
Si no hace una cita dentro de 60 diacuteas a partir de recibir la lista regional de proveedores no le seraacute permitido tener una segunda o tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si el meacutedico de la segunda opinioacuten siente que su lesioacuten estaacute fuera del tipo de lesioacuten que eacutel o eacutella normalmente trata la oficina del meacutedico le notificaraacute a su empleador o compantildeiacutea de seguros y usted obtendraacute otra lista de meacutedicos o especialistas de la MPN para que pueda hacer otra seleccioacuten
Si usted no estaacute de acuerdo con la segunda opinioacuten puede pedir por una tercera opinioacuten Si usted pide una tercera opinioacuten usted pasaraacute por el mismo proceso que pasoacute para la segunda opinioacuten
Recuerde que si no hace una cita dentro de 60 diacuteas a partir de recibir la otra lista de proveedores de la MPN entonces no le seraacute permitido tener una tercera opinioacuten sobre el disputado diagnosis o tratamiento recomendado por el meacutedico que lo estaacute atendiendo
Si usted no estaacute de acuerdo con el meacutedico de la tercera opinioacuten usted puede pedir una MPN Revisioacuten Meacutedica Independiente o IMR (Independent Medical Review) Su empleador o el contacto de la MPN le daraacute informacioacuten sobre coacutemo pedir la Revisioacuten Meacutedica Independiente y un formulario cuando usted selecciona la tercera opinioacuten meacutedica
Si el meacutedico o Revisor Medico Independiente de la segunda o tercera opinioacuten estaacute de acuerdo que usted necesita algun tratamiento o anaacutelisis le seraacute tal vez permitido recibir el servicio meacutedico de un proveedor dentro de la MPN o si la MPN no tiene un medico quien puede proveer el tratamiento puede elegir a un medico fuera de la MPN dentro de una aacuterea geografic razonable
Queacute tal si ya estoy siendo atendido por una lesioacuten de trabajo antes de que empieze la MPN
Su empleador o la compantildeiacutea de seguros tiene un plan de ldquoTransferencia de Cuidadordquo que determinaraacute si usted puede continuar siendo temporalmente atendido por una lesioacuten de trabajo por un meacutedico fuera de la MPN antes de que su cuidado sea transferido a la MPN
Si su meacutedico actual no es o no se convierte en un miembro de la MPN entonces podraacute ser obligado ver
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Care West Insurance Company ndashCare West MPN
Su empleador o compantildeiacutea de seguros tiene un plan escrito para ldquoLa Continuidad de Cuidadordquo que determinaraacute si es que podraacute continuar temporalmente su tratamiento por su lesioacuten de trabajo actual con su meacutedico si su meacutedico ya no estaacute participando en la MPN
Si su empleador decide que usted no califica para continuar su tratamiento con el meacutedico que no es un proveedor dentro de la MPN usted y el meacutedico que lo estaacute atendiendo deberaacuten recibir una carta notificaacutendole de esta decisioacuten
Si usted llena ciertos requisitos tal vez podraacute calificar para continuar su tratamiento con este meacutedico hasta por un antildeo antes de que tenga que elegir a un meacutedico de la MPN Estos requisitos estaacuten expuestos ldquoiquestPuedo Continuar Ser Tratado Por Mi Meacutedicordquo en la caja descrita arriba
Usted puede no estar de acuerdo con la decisioacuten de su empleador sobre negarle la Continuidad de Cuidado con el proveedor que ya no es parte de la MPN Si quiere continuar su tratamiento con este meacutedico piacutedale al meacutedico que lo estaacute atendiendo por un informe que indique si tiene una de las cuatro condiciones descritas en la caja de arriba para ver si califica para seguir recibiendo tratamiento de su meacutedico actual
El meacutedico que lo estaacute atendiendo tiene 20 diacuteas a partir de la fecha de su peticioacuten para darle una copia del informe sobre su condicioacuten Si el meacutedico que lo estaacute atendiendo no le da el informe dentro de los 20 diacuteas a partir de la fecha de su peticioacuten la decisioacuten de su empleador de negale la Continuidad de Cuidado con su doctor quien ya no participa en la MPN aplicara y usted seraacute requerido a escoger un meacutedico de la MPN
Tendraacute que darle una copia del informe a su empleador si desea posponer la seleccion de un tratamiento con un medico de la MPN Si usted o su empleador no estaacute de acuerdo con el informe de su meacutedico sobre su condicioacuten usted o su empleador puede disputarlo Vea el plan de transferencia de cuidado para maacutes detalles sobre el proceso de resolucioacuten de disputa
Para una copia del plan de la Continuidad de Cuidado en ingleacutes o espantildeol preguacutentele a su Contacto de la MPN
iquestQueacute tal si tengo preguntas o necesito ayuda
El Contacto de la MPN Usted siempre puede ponerse en contacto con el Contacto de la MPN si tiene preguntas sobre el uso de la MPN y como mandra sus reclamos respecto a la MPN
Medical Access Assistants You can contact the Medical Access Assistant if you need help finding MPN physicians and scheduling and confirming appointments
Correo electroacutenico mpninfonetbydcom
La Divisioacuten de Compensacioacuten de Trabajadores (DWC) Si tiene alguacuten intereacutes queja pregunta sobre la MPN el proceso de notificacioacuten o su tratamiento meacutedico despueacutes de una lesioacuten oenfermedad de trabajo puede llamar a la Oficina de Informacioacuten y Asistencia de la DWC al 1-800-736-7401 Tambieacuten puede consultar con la paacutegina web de la DWC en el wwwdircagovdwc y haga clic en ldquola red de proveedores meacutedicosrdquo para maacutes informacioacuten sobre las MPNs
Revisioacuten Meacutedica Independiente Si usted tiene preguntas sobre el MPN proceso de la Revisioacuten Meacutedica Independiente poacutengase en contacto con la Unidad Meacutedica de la Divisioacuten de Compensacioacuten de Trabajadores en
DWC Medical UnitPO Box 71010Oakland CA 94612(510) 286-3700 or (800) 794-6900
Mantenga esta informacion en caso de una lesion o enfermedadrelacionada con el trabajo
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
MPN Notifications
amp Procedures
Instructions
MPN ndash Employer Acknowledgement English Spanish
Notice to All Employees ndash Injuries Caused by Work
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
MEDICAL PROVIDER NETWORK INSTRUCTIONS
Care West Insurance Company has implemented a Medical Provider Network (MPN) with The
State of California in order to provide your employeersquos with qualified physicians in a
multitude of specialties to meet their treatment needs You will be selecting your initial entry
provider that will be documented on your MPN Poster and provided separate from the
process noted below
The State of California requires that a thirty (30) day notice be provided to employees in
order to implement compliance with the Medical Provider Network (MPN) Absent the
required notification an employee may treat with any physician or facility they select
Existing Employees
Each employee must complete and sign the ldquoNotification of Medical Provider
Networkrdquo form Please note that you must pre-fill the name of the individual to
whom the form will be returned and the effective date of the MPN The effective
date of the MPN is 30 days following the date you provide this form to your
employees This form is provided in English and Spanish
New Hires
As part of your New Hire process the new employee must complete and sign the
ldquoMPN ndash Employee Acknowledgementrdquo form Please note that you must pre-fill the
name of the individual to whom the form will be returned and the effective date of
the MPN The effective date of the MPN is the 30th day following the date you
provided the form to the employee
Note If you are new to Care West Insurance Company and you have not completed the
Medical Provider Network designation call you will be receiving a call shortly to complete
this process and answer any questions You may also contact us by phone at (209) 549-3020
or (888) 312-5246 with any questions
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
MPN ndash EMPLOYEE ACKNOWLEDGEMENT
Date _____________________
Dear Employee
Please read the following information sign and return this form to
_________________________ as soon as possible
Unless you predesignate a physician or medical group your new work injuries
arising on or after ______________________ ___ will be treated by providers in a new (Enter Effective Date)
Medical Provider Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing
injury you may be required to continue care under your prior MPN or to change to a provider in
the new MPN check with your claims adjuster You may obtain more information about the
MPN from The Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or
888-312-5246 wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand the above
information
SIGN ___________________________________________
DATE ___________________________________________
WITNESS ________________________________________
(Please retain a copy for your records)
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
MPN - RECONOCIMIENTO DEL EMPLEADO
Fecha _____________________
Estimado Empleado
Por favor lea la siguiente informacioacuten firmar y devolver este formulario a
_________________________ tan pronto como sea posible
A menos que se predesignate un meacutedico o un grupo meacutedico sus nuevas lesiones
de trabajo derivados en o despueacutes del ______________________ ___ seraacuten tratadas por (Enter Effective Date)
los proveedores en una nueva red de proveedor meacutedico La atencioacuten de Occidente
proveedor red meacutedica Si tienes una lesioacuten existente puede exigirse para continuar la
asistencia en el MPN previa o cambiar a un proveedor en el MPN nuevo consulte con su
ajustador de reclamos Puede obtener maacutes informacioacuten acerca de la MPN de oeste de
cuidado el MPN PO Box 5038 Modesto CA 95352 teleacutefono 209-549-3020 o 888-
312-5246 wwwcarewestinscom
____________________________ reconozco que han recibido y entender la informacioacuten
anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(Por favor Conserve una copia para sus archivos)
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
NOTIFICATION OF MEDICAL PROVIDER NETWORK (MPN)
Date _____________________
To All Employees
Our Workersrsquo Compensation carrier has changed Please read the following information
sign and return this form to _________________________ as soon as possible
The __________________MPN will no longer be used for work injuries arising after
_______________ You will not continue to use this MPN to obtain care for work injuries
occurring after this date You may obtain more information at _______________
For new injuries that occur when you are not covered by an MPN you have the right to
choose your physician 30 days after you notify your employer of your injury
Unless you predesignate a physician or medical group your new work injuries arising on
or after ______________________ will be treated by providers in a new Medical Provider (Enter Effective Date)
Network ldquoThe Care West Medical Provider Networkrdquo If you have an existing injury you may be
required to continue care under your prior MPN or to change to a provider in the new MPN
check with your claims adjuster You may obtain more information about the MPN from The
Care West MPN PO Box 5038 Modesto CA 95352 Phone 209-549-3020 or 888-312-5246
wwwcarewestinscom
I ____________________________ acknowledge that I have received and understand
the above information
SIGN ____________________________________________
DATE ____________________________________________
WITNESS _________________________________________
(employer please be sure to keep one copy for your records and give a copy to the employee)
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
NOTIFICACIOacuteN DE Red de Proveedores Meacutedicos (MPN)
Fecha ___________________
A todos los em pleados
Ha cambiado nuestra compafifa de compensacion de trabajadores Por favor leen la
siguiente informacion firman y devolucion este formulario a __________________________
tan pronto como sea posible
El MPN ya nose utilizani para las lesiones de trabajo derivados despues Nose seguini
utilizar este MPN para obtener atencion para lesiones de trabajo posteriores a esta fecha Puede
obtener mas informacion como ________________________
Para nuevas lesiones que se producen cuando usted no esta cubierto por un MPN
usted tiene derecho a elegir a su medico 30 dfas despues de que notifique a su empleador
de su lesion
A menos que se predesignate un medico o un grupo medico sus nuevas lesiones de
trabajo derivados en o despues del _________________________ seran tratadas por los (Enter Effective Date)
proveedores en una nueva red de proveedor medico La atencion de Occidente proveedor red
medica Si tienes una lesion existente puede exigirse para continuar Ia asistencia en el MPN
previa o cambiar a un proveedor en el MPN nuevo consulte con su ajustador de reclamos
Puede obtener mas informacion acerca de Ia MPN de oeste de cuidado el MPN PO Box 5038
Modesto CA 95352 telefono 209-549-3020 o 888- 312-5246 wwwcarewestinscom
_____________________ reconozco que han recibido y entender Ia informacion anterior
FIRMAR ____________________________________________
FECHA _____________________________________________
FE ________________________________________________
(empleador Asegurese mantener una co pia de sus registros y dar una co pia al empleado)
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
PREDESIGNATION OF PERSONAL PHYSICIAN In the event you sustain an injury or illness related to your employment you may be treated for such injury or illness by your personal medical doctor (MD) doctor of osteopathic medicine (DO) or medical group if
bull on the date of your work injury you have health care coverage for injuries or illnesses that are not workrelated
bull the doctor is your regular physician who shall be either a physician who has limited his or her practice ofmedicine to general practice or who is a board-certified or board-eligible internist pediatricianobstetrician-gynecologist or family practitioner and has previously directed your medical treatment andretains your medical records
bull your ldquopersonal physicianrdquo may be a medical group if it is a single corporation or partnership composed oflicensed doctors of medicine or osteopathy which operates an integrated multispecialty medical groupproviding comprehensive medical services predominantly for nonoccupational illnesses and injuries
bull prior to the injury your doctor agrees to treat you for work injuries or illnessesbull prior to the injury you provided your employer the following in writing (1) notice that you want your
personal doctor to treat you for a work-related injury or illness and (2) your personal doctors name andbusiness address
You may use this form to notify your employer if you wish to have your personal medical doctor or a doctor of osteopathic medicine treat you for a work-related injury or illness and the above requirements are met
NOTICE OF PREDESIGNATION OF PERSONAL PHYSICIAN Employee Complete this section
To ____________________________ (name of employer) If I have a work-related injury or illness I choose to be treated by _________________________________________________________________ (name of doctor)(MD DO or medical group) _________________________________________________________________ (street address city state ZIP)
__________________________________________________ (telephone number)
Employee Name (please print) _____________________________________________________________________________________________
Employees Address _____________________________________________________________________________________________
Name of Insurance Company Plan or Fund providing health coverage for nonoccupational injuries or illnesses
Employees Signature ________________________________Date __________
Physician I agree to this Predesignation
Signature _________________ ___________________________Date __________ (Physician or Designated Employee of the Physician or Medical Group)
The physician is not required to sign this form however if the physician or designated employee of the physician or medical group does not sign other documentation of the physicians agreement to be predesignated will be required pursuant to Title 8 California Code of Regulations section 97801(a)(3)
Title 8 California Code of Regulations section 9783
Predesignation of Personal Physician Reporting Duties of the Primary Treating Physician Regulations 8 CCR section 9780 et seq (Approved 02122014)
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Reporting amp Injury
How to report a new injury or illness
Identifying First Aid Only Claims
DWC-1 ndash Workersrsquo Compensation Claim Form
5020 ndash Employers Report of Occupational Injury or Illness
Supervisor Accident Report
Required Supervisor injury forms
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
REPORT A NEW INJURY OR ILLNESS
Immediately upon knowledge of an incident that may give rise to an injury you must offer medical treatment
to your employee at your designated facility or through a pre-designated physician if the employee has
chosen one prior to injury
Once you have addressed medical assistance needs the following forms must be completed and submitted at
the earliest possible moment but not to exceed five (5) days in any event
EMPLOYER
bull Employerrsquos First Report of Injury (Form 5020) Must be completed fully
bull Injury amp Illness Supervisor Report
bull Employer portion of DWC-1 once Employee has completed their portion
(The employee must completed their portion of the DWC-1)
NOTE If there are witnesses to the injury please secure written statements
EMPLOYEE
bull DWC-1 Form
bull Complete and sign the Medical Authorization Form
bull Sign Fraud Statement
bull Complete body part chart
SUBMISSION
All forms should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839 and
originals mailed to PO Box 5038 Modesto CA 95352 As the employee follows up for medical attention all
work status slips and other medical slips given to the employee should be faxed to the claims unit upon
your receipt
Upon receipt of the above paperwork Care Westrsquos Claims Unit will set up a claim and assign to a Claims
Examiner who will contact you with claim information
NOTE Above forms can also be obtained at Care West Insurance Companies website as follows
wwwcarewestinscom
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
IDENTIFYING FIRST AID CLAIMS
Your claim may be considered first aid if
bull Physician visits are limited to 1 initial and follow up with the designated facility
bull Only over the counter medications are recommended by the physician
bull There are no stitches involved in treating the injury
bull The employee is returned to full duties with no modifications
bull No invasive treatment is needed other than the administration of a Tetanus injection
The WCIRB requires that all incidents or injuries that require a physician visit be reported to the insurance
carrier and The State including first aid claims In addition the WCIRB has issued an amendment to Labor
Code Section 5401(a) effective 112017 requiring the cost of treatment for ldquofirst aidrdquo claims also be reported
Care West Insurance Company will track your claim issue payment for the bills and report on your behalf per
the new requirement
EMPLOYER RESPONSIBILITIES
bull Fully complete the Employerrsquos First Report of Injury (Form 5020)
bull Note on the form that you believe the claim is a first aid claim
bull Fax the form to Care Westrsquos Claims Unit as noted below within five (5) days of
knowledge of incident andor injury that requires a physician visit
Care Westrsquos Claims Unit will assign the claim to an adjuster to contact you with acknowledgement and verify
first aid status If the claim falls within first aid only policy as specified by The State of California no other
forms are required to be completed
The Form 5020 should be completed as noted above and faxed to Care West Claimrsquos Unit at (209) 574-2839
within five (5) days of knowledge of incident andor injury
NOTE The above form can also be accessed at Care West Insurance Companies website as follows
wwwcarewestinscom
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Rev 112016 Page 1 of 3
Workersrsquo Compensation Claim Form (DWC 1) amp Notice of Potential Eligibility Formulario de Reclamo de Compensacioacuten de Trabajadores (DWC 1) y Notificacioacuten de Posible Elegibilidad If you are injured or become ill either physically or mentally because of your job including injuries resulting from a workplace crime you may be entitled to workersrsquo compensation benefits Use the attached form to file a workersrsquo compensation claim with your employer You should read all of the information below Keep this sheet and all other papers for your records You may be eligible for some or all of the benefits listed depending on the nature of your claim If you file a claim the claims administrator who is responsible for handling your claim must notify you within 14 days whether your claim is accepted or whether additional investigation is needed
To file a claim complete the ldquoEmployeerdquo section of the form keep one copy and give the rest to your employer Do this right away to avoid problems with your claim In some cases benefits will not start until you inform your employer about your injury by filing a claim form Describe your injury completely Include every part of your body affected by the injury If you mail the form to your employer use first-class or certified mail If you buy a return receipt you will be able to prove that the claim form was mailed and when it was delivered Within one working day after you file the claim form your employer must complete the ldquoEmployerrdquo section give you a dated copy keep one copy and send one to the claims administrator
Medical Care Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness Medical benefits are subject to approval and may include treatment by a doctor hospital services physical therapy lab tests x-rays medicines equipment and travel costs Your claims administrator will pay the costs of approved medical services directly so you should never see a bill There are limits on chiropractic physical therapy and other occupational therapy visits
The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness If you previously designated your personal physician or a medical group
you may see your personal physician or the medical group after you are injured
If your employer is using a medical provider network (MPN) or Health CareOrganization (HCO) in most cases you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group An MPN is a group of health care providers who provide treatment to workers injured on the job You should receive information from your employer if you are covered by an HCO or a MPN Contact your employer for more information
If your employer is not using an MPN or HCO in most cases the claimsadministrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group
If your employer has not put up a poster describing your rights to workersrsquocompensation you may be able to be treated by your personal physician right after you are injured
Within one working day after you file a claim form your employer or the claims administrator must authorize up to $10000 in treatment for your injury consistent with the applicable treating guidelines until the claim is accepted or rejected If the employer or claims administrator does not authorize treatment right away talk to your supervisor someone else in management or the claims administrator Ask for treatment to be authorized right now while waiting for a decision on your claim If the employer or claims administrator will not authorize treatment use your own health insurance to get medical care Your health insurer will seek reimbursement from the claims administrator If you do not have health insurance there are doctors clinics or hospitals that will treat you without immediate payment They will seek reimbursement from the claims administrator
Switching to a Different Doctor as Your PTP If you are being treated in a Medical Provider Network (MPN) you may
switch to other doctors within the MPN after the first visit If you are being treated in a Health Care Organization (HCO) you may
switch at least one time to another doctor within the HCO You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance)
If you are not being treated in an MPN or HCO and did not predesignateyou may switch to a new doctor one time during the first 30 days after your injury is reported to your employer Contact the claims administrator to switch doctors After 30 days you may switch to a doctor of your choice if
Si Ud se lesiona o se enferma ya sea fiacutesicamente o mentalmente debido a su trabajo incluyendo lesiones que resulten de un crimen en el lugar de trabajo es posible que Ud tenga derecho a beneficios de compensacioacuten de trabajadores Utilice el formulario adjunto para presentar un reclamo de compensacioacuten de trabajadores con su empleador Ud debe leer toda la informacioacuten a continuacioacuten Guarde esta hoja y todos los demaacutes documentos para sus archivos Es posible que usted reuacutena los requisitos para todos los beneficios o parte de eacutestos que se enumeran dependiendo de la iacutendole de su reclamo Si usted presenta un reclamo l administrador de reclamos quien es responsable por el manejo de su reclamo debe notificarle dentro de 14 diacuteas si se acepta su reclamo o si se necesita investigacioacuten adicional
Para presentar un reclamo llene la seccioacuten del formulario designada para el ldquoEmpleadordquo guarde una copia y deacutele el resto a su empleador Haga esto de inmediato para evitar problemas con su reclamo En algunos casos los beneficios no se iniciaraacuten hasta que usted le informe a su empleador acerca de su lesioacuten mediante la presentacioacuten de un formulario de reclamo Describa su lesioacuten por completo Incluya cada parte de su cuerpo afectada por la lesioacuten Si usted le enviacutea por correo el formulario a su empleador utilice primera clase o correo certificado Si usted compra un acuse de recibo usted podraacute demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado Dentro de un diacutea laboral despueacutes de presentar el formulario de reclamo su empleador debe completar la seccioacuten designada para el ldquoEmpleadorrdquo le daraacute a Ud una copia fechada guardaraacute una copia y enviaraacute una al administrador de reclamos
Atencioacuten Meacutedica Su administrador de reclamos pagaraacute por toda la atencioacuten meacutedica razonable y necesaria para su lesioacuten o enfermedad relacionada con el trabajo Los beneficios meacutedicos estaacuten sujetos a la aprobacioacuten y pueden incluir tratamiento por parte de un meacutedico los servicios de hospital la terapia fiacutesica los anaacutelisis de laboratorio las medicinas equipos y gastos de viaje Su administrador de reclamos pagaraacute directamente los costos de los servicios meacutedicos aprobados de manera que usted nunca veraacute una factura Hay liacutemites en terapia quiropraacutectica fiacutesica y otras visitas de terapia ocupacional
El Meacutedico Primario que le Atiende (Primary Treating Physician- PTP) es el meacutedico con la responsabilidad total para tratar su lesioacuten o enfermedad Si usted designoacute previamente a su meacutedico personal o a un grupo meacutedico
usted podraacute ver a su meacutedico personal o grupo meacutedico despueacutes de lesionarse Si su empleador estaacute utilizando una red de proveedores meacutedicos (Medical
Provider Network- MPN) o una Organizacioacuten de Cuidado Meacutedico (Health Care Organization- HCO) en la mayoriacutea de los casos usted seraacute tratado en la MPN o HCO a menos que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico Una MPN es un grupo de proveedores de asistencia meacutedica quien da tratamiento a los trabajadores lesionados en el trabajo Usted debe recibir informacioacuten de su empleador si su tratamiento es cubierto por una HCO o una MPN Hable con su empleador para maacutes informacioacuten
Si su empleador no estaacute utilizando una MPN o HCO en la mayoriacutea de loscasos el administrador de reclamos puede elegir el meacutedico que lo atiende primero a menos de que usted hizo una designacioacuten previa de su meacutedico personal o grupo meacutedico
Si su empleador no ha colocado un cartel describiendo sus derechos para lacompensacioacuten de trabajadores Ud puede ser tratado por su meacutedico personal inmediatamente despueacutes de lesionarse
Dentro de un diacutea laboral despueacutes de que Ud Presente un formulario de reclamo su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesioacuten de acuerdo con las pautas de tratamiento aplicables hasta que el reclamo sea aceptado o rechazado Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato hable con su supervisor alguien maacutes en la gerencia o con el administrador de reclamos Pida que el tratamiento sea autorizado ya mismo mientras espera una decisioacuten sobre su reclamo Si el empleador o administrador de reclamos no autoriza el tratamiento utilice su propio seguro meacutedico para recibir atencioacuten meacutedica Su compantildeiacutea de seguro meacutedico buscaraacute reembolso del administrador de reclamos Si usted no tiene seguro meacutedico hay meacutedicos cliacutenicas u hospitales que lo trataraacuten sin pago inmediato Ellos buscaraacuten reembolso del administrador de reclamos
Cambiando a otro Meacutedico Primario o PTP Si usted estaacute recibiendo tratamiento en una Red de Proveedores Meacutedicos
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Rev 112016 Page 2 of 3
your employer or the claims administrator has not created or selected an MPN
Disclosure of Medical Records After you make a claim for workers compensation benefits your medical records will not have the same level of privacy that you usually expect If you donrsquot agree to voluntarily release medical records a workersrsquo compensation judge may decide what records will be released If you request privacy the judge may seal (keep private) certain medical records
Problems with Medical Care and Medical Reports At some point during your claim you might disagree with your PTP about what treatment is necessary If this happens you can switch to other doctors as described above If you cannot reach agreement with another doctor the steps to take depend on whether you are receiving care in an MPN HCO or neither For more information see ldquoLearn More About Workersrsquo Compensationrdquo below
If the claims administrator denies treatment recommended by your PTP you may request independent medical review (IMR) using the request form included with the claims administratorrsquos written decision to deny treatment The IMR process is similar to the group health IMR process and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given Your attorney or your physician may assist you in the IMR process IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician
If you disagree with your PTP on matters other than treatment such as the cause of your injury or how severe the injury is you can switch to other doctors as described above If you cannot reach agreement with another doctor notify the claims administrator in writing as soon as possible In some cases you risk losing the right to challenge your PTPrsquos opinion unless you do this promptly If you do not have an attorney the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute If you have an attorney the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME) If the claims administrator disagrees with your PTP on matters other than treatment the claims administrator can require you to be seen by a QME or AME
Payment for Temporary Disability (Lost Wages) If you cant work while you are recovering from a job injury or illness you may receive temporary disability payments for a limited period These payments may change or stop when your doctor says you are able to return to work These benefits are tax-free Temporary disability payments are two-thirds of your average weekly pay within minimums and maximums set by state law Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days
Stay at Work or Return to Work Being injured does not mean you must stop working If you can continue working you should If not it is important to go back to work with your current employer as soon as you are medically able Studies show that the longer you are off work the harder it is to get back to your original job and wages While you are recovering your PTP your employer (supervisors or others in management) the claims administrator and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do Actively communicate with your PTP your employer and the claims administrator about the work you did before you were injured your medical condition and the kinds of work you can do now and the kinds of work that your employer could make available to you
Payment for Permanent Disability If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do you may receive additional payments The amount will depend on the type of injury extent of impairment your age occupation date of injury and your wages before you were injured
Supplemental Job Displacement Benefit (SJDB) If you were injured on or after 1104 and your injury results in a permanent disability and your employer does not offer regular modified or alternative work you may qualify for a nontransferable voucher payable for retraining andor skill enhancement If you qualify the claims administrator will pay the costs up to the maximum set by state law
Death Benefits If the injury or illness causes death payments may be made to a
(Medical Provider Network- MPN) usted puede cambiar a otros meacutedicos dentro de la MPN despueacutes de la primera visita
Si usted estaacute recibiendo tratamiento en un Organizacioacuten de Cuidado Meacutedico (Healthcare Organization- HCO) es posible cambiar al menos una vez a otro meacutedico dentro de la HCO Usted puede cambiar a un meacutedico fuera de la HCO 90 o 180 diacuteas despueacutes de que su lesioacuten es reportada a su empleador (dependiendo de si usted estaacute cubierto por un seguro meacutedico proporcionado por su empleador)
Si usted no estaacute recibiendo tratamiento en una MPN o HCO y no hizo una designacioacuten previa usted puede cambiar a un nuevo meacutedico una vez durante los primeros 30 diacuteas despueacutes de que su lesioacuten es reportada a su empleador Poacutengase en contacto con el administrador de reclamos para cambiar de meacutedico Despueacutes de 30 diacuteas puede cambiar a un meacutedico de su eleccioacuten si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN
Divulgacioacuten de Expedientes Meacutedicos Despueacutes de que Ud presente un reclamo para beneficios de compensacioacuten de trabajadores sus expedientes meacutedicos no tendraacuten el mismo nivel de privacidad que usted normalmente espera Si Ud no estaacute de acuerdo en divulgar voluntariamente los expedientes meacutedicos un juez de compensacioacuten de trabajadores posiblemente decida queacute expedientes seraacuten revelados Si usted solicita privacidad es posible que el juez ldquosellerdquo (mantenga privados) ciertos expedientes meacutedicos
Problemas con la Atencioacuten Meacutedica y los Informes Meacutedicos En alguacuten momento durante su reclamo podriacutea estar en desacuerdo con su PTP sobre queacute tratamiento es necesario Si esto sucede usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico los pasos a seguir dependen de si usted estaacute recibiendo atencioacuten en una MPN HCO o ninguna de las dos Para maacutes informacioacuten consulte la seccioacuten ldquoAprenda Maacutes Sobre la Compensacioacuten de Trabajadoresrdquo a continuacioacuten
Si el administrador de reclamos niega el tratamiento recomendado por su PTP puede solicitar una revisioacuten meacutedica independiente (Independent Medical Review- IMR) utilizando el formulario de solicitud que se incluye con la decisioacuten por escrito del administrador de reclamos negando el tratamiento El proceso de la IMR es parecido al proceso de la IMR de un seguro meacutedico colectivo y tarda aproximadamente 40 (o menos) diacuteas para llegar a una determinacioacuten de manera que se pueda dar un tratamiento apropiado Su abogado o su meacutedico le pueden ayudar en el proceso de la IMR La IMR no estaacute disponible para resolver disputas sobre cuestiones aparte de la necesidad meacutedica de un tratamiento particular solicitado por su meacutedico
Si no estaacute de acuerdo con su PTP en cuestiones aparte del tratamiento como la causa de su lesioacuten o la gravedad de la lesioacuten usted puede cambiar a otros meacutedicos como se describe anteriormente Si no puede llegar a un acuerdo con otro meacutedico notifique al administrador de reclamos por escrito tan pronto como sea posible En algunos casos usted arriesg perder el derecho a objetar a la opinioacuten de su PTP a menos que hace esto de inmediato Si usted no tiene un abogado el administrador de reclamos debe enviarle instrucciones para ser evaluado por un meacutedico llamado un evaluador meacutedico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa Si usted tiene un abogado el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un meacutedico llamado un evaluador meacutedico acordado (Agreed Medical Evaluator- AME) Si el administrador de reclamos no estaacute de acuerdo con su PTP sobre asuntos aparte del tratamiento el administrador de reclamos puede exigirle que sea atendido por un QME o AME
Pago por Incapacidad Temporal (Sueldos Perdidos) Si Ud no puede trabajar mientras se estaacute recuperando de una lesioacuten o enfermedad relacionada con el trabajo Ud puede recibir pagos por incapacidad temporal por un periodo limitado Estos pagos pueden cambiar o parar cuando su meacutedico diga que Ud estaacute en condiciones de regresar a trabajar Estos beneficios son libres de impuestos Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio con cantidades miacutenimas y maacuteximas establecidas por las leyes estales Los pagos no se hacen durante los primeros tres diacuteas en que Ud no trabaje a menos que Ud sea hospitalizado una noche o no puede trabajar durante maacutes de 14 diacuteas
Permanezca en el Trabajo o Regreso al Trabajo Estar lesionado no significa que usted debe dejar de trabajar Si usted puede seguir trabajando usted debe hacerlo Si no es asiacute es importante regresar a trabajar con su empleador actual tan
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Rev 112016 Page 3 of 3
spouse and other relatives or household members who were financially dependent on the deceased worker
It is illegal for your employer to punish or fire you for having a job injury or illness for filing a claim or testifying in another persons workers compensation case (Labor Code 132a) If proven you may receive lost wages job reinstatement increased benefits and costs and expenses up to limits set by the state
Resolving Problems or Disputes You have the right to disagree with decisions affecting your claim If you have a disagreement contact your employer or claims administrator first to see if you can resolve it If you are not receiving benefits you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606 or go to their website at wwweddcagov
You Can Contact an Information amp Assistance (IampA) Officer State IampA officers answer questions help injured workers provide forms and help resolve problems Some IampA officers hold workshops for injured workers To obtain important information about the workersrsquo compensation claims process and your rights and obligations go to wwwdwccagov or contact an IampA officer of the state Division of Workersrsquo Compensation You can also hear recorded information and a list of local IampA offices by calling (800) 736-7401
You can consult with an attorney Most attorneys offer one free consultation If you decide to hire an attorney his or her fee will be taken out of some of your benefits For names of workers compensation attorneys call the State Bar of California at (415) 538-2120 or go to their website at www californiaspecialistorg
Learn More About Workersrsquo Compensation For more information about the workersrsquo compensation claims process go to wwwdwccagov At the website you can access a useful booklet ldquoWorkersrsquo Compensation in California A Guidebook for Injured Workersrdquo You can also contact an Information amp Assistance Officer (above) or hear recorded information by calling 1-800-736-7401
pronto como usted pueda medicamente hacerlo Los estudios demuestran que entre maacutes tiempo esteacute fuera del trabajo maacutes difiacutecil es regresar a su trabajo original y a sus salarios Mientras se estaacute recuperando su PTP su empleador (supervisores u otras personas en la gerencia) el administrador de reclamos y su abogado (si tiene uno) trabajaraacuten con usted para decidir coacutemo va a permanecer en el trabajo o regresar al trabajo y queacute trabajo haraacute Comuniacutequese de manera activa con su PTP su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse su condicioacuten meacutedica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podriacutea poner a su disposicioacuten
Pago por Incapacidad Permanente Si un meacutedico dice que no se ha recuperado completamente de su lesioacuten y siempre seraacute limitado en el trabajo que puede hacer es posible que Ud reciba pagos adicionales La cantidad dependeraacute de la clase de lesioacuten grado de deterioro su edad ocupacioacuten fecha de la lesioacuten y sus salarios antes de lesionarse
Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB) Si Ud se lesionoacute en o despueacutes del 1104 y su lesioacuten resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular modificado o alternativo usted podriacutea cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento yo mejorar su habilidad Si Ud cumple los requisios el administrador de reclamos pagaraacute los gastos hasta un maacuteximo establecido por las leyes estatales
Beneficios por Muerte Si la lesioacuten o enfermedad causa la muerte es posible que los pagos se hagan a un coacutenyuge y otros parientes o a las personas que viven en el hogar que dependiacutean econoacutemicamente del trabajador difunto
Es ilegal que su empleador le castigue o despida por sufrir una lesioacuten o enfermedad laboral por presentar un reclamo o por testificar en el caso de compensacioacuten de trabajadores de otra persona (Coacutedigo Laboral seccioacuten 132a) De ser probado usted puede recibir pagos por peacuterdida de sueldos reposicioacuten del trabajo aumento de beneficios y gastos hasta los liacutemites establecidos por el estado
Resolviendo problemas o disputas Ud tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo Si Ud tiene un desacuerdo primero comuniacutequese con su empleador o administrador de reclamos para ver si usted puede resolverlo Si usted no estaacute recibiendo beneficios es posible que Ud pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI) Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606 o visite su paacutegina Web en wwweddcagov
Puede Contactar a un Oficial de Informacioacuten y Asistencia (Information amp Assistance- IampA) Los Oficiales de Informacioacuten y Asistencia (IampA) estatal contestan preguntas ayudan a los trabajadores lesionados proporcionan formularios y ayudan a resolver problemas Algunos oficiales de IampA tienen talleres para trabajadores lesionados Para obtener informacioacuten importante sobre el proceso de la compensacioacuten de trabajadores y sus derechos y obligaciones vaya a wwwdwccagov o comuniacutequese con un oficial de informacioacuten y asistencia de la Divisioacuten Estatal de Compensacioacuten de Trabajadores Tambieacuten puede escuchar informacioacuten grabada y una lista de las oficinas de IampA locales llamando al (800) 736-7401
Ud puede consultar con un abogado La mayoriacutea de los abogados ofrecen una consulta gratis Si Ud decide contratar a un abogado los honorarios seraacuten tomados de algunos de sus beneficios Para obtener nombres de abogados de compensacioacuten de trabajadores llame a la Asociacioacuten Estatal de Abogados de California (State Bar) al (415) 538-2120 o consulte su paacutegina Web en wwwcaliforniaspecialistorg
Aprenda Maacutes Sobre la Compensacioacuten de Trabajadores Para obtener maacutes informacioacuten sobre el proceso de reclamos del programa de compensacioacuten de trabajadores vaya a wwwdwccagov En la paacutegina Web podraacute acceder a un folleto uacutetil ldquoCompensacioacuten del Trabajador de California Una Guiacutea para Trabajadores Lesionadosrdquo Tambieacuten puede contactar a un oficial de Informacioacuten y Asistencia (arriba) o escuchar informacioacuten grabada llamando al 1-800-736-7401
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Rev 112016
State of California Department of Industrial Relations DIVISION OF WORKERSrsquo COMPENSATION
WORKERSrsquo COMPENSATION CLAIM FORM (DWC 1)
Estado de California Departamento de Relaciones Industriales
DIVISION DE COMPENSACIOacuteN AL TRABAJADOR
PETITION DEL EMPLEADO PARA DE COMPENSACIOacuteN DEL TRABAJADOR (DWC 1)
Employee Complete the ldquoEmployeerdquo section and give the form to your employer Keep a copy and mark it ldquoEmployeersquos Temporary Receiptrdquo until you receive the signed and dated copy from your employer You may call the Division of Workersrsquo Compensation and hear recorded information at (800) 736-7401 An explanation of workers compensation benefits is included in the Notice of Potential Eligibility which is the cover sheet of this form Detach and save this notice for future reference You should also have received a pamphlet from your employer describing workersrsquo compensation benefits and the procedures to obtain them You may receive written notices from your employer or its claims administrator about your claim If your claims administrator offers to send you notices electronically and you agree to receive these notices only by email please provide your email address below and check the appropriate box If you later decide you want to receive the notices by mail you must inform your employer in writing
Empleado Complete la seccioacuten ldquoEmpleadordquo y entregue la forma a su empleador Queacutedese con la copia designada ldquoRecibo Temporal del Empleadordquo hasta que Ud reciba la copia firmada y fechada de su empleador Ud puede llamar a la Division de Compensacioacuten al Trabajador al (800) 736- 7401 para oir informacioacuten gravada Una explicacioacuten de los beneficios de compensacioacuten de trabajadores estaacute incluido en la Notificacioacuten de Posible Elegibilidad que es la hoja de portada de esta forma Separe y guarde esta notificacioacuten como referencia para el futuro
Ud tambieacuten deberiacutea haber recibido de su empleador un folleto describiendo los benficios de compensacioacuten al trabajador lesionado y los procedimientos para obtenerlos Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo Si su administrador de reclamos ofrece enviarle notificaciones electroacutenicamente y usted acepta recibir estas notificaciones solo por correo electroacutenico por favor proporcione su direccioacuten de correo electroacutenico abajo y marque la caja apropiada Si usted decide despueacutes que quiere recibir las notificaciones por correo usted debe de informar a su empleador por escrito
Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workersrsquo compensation benefits or payments is guilty of a felony
Toda aquella persona que a propoacutesito haga o cause que se produzca cualquier declaracioacuten o representacioacuten material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensacioacuten a trabajadores lesionados es culpable de un crimen mayor ldquofeloniardquo
Employeemdashcomplete this section and see note above Empleadomdashcomplete esta seccioacuten y note la notacioacuten arriba 1 Name Nombre ___________________________________________________ Todayrsquos Date Fecha de Hoy ____________________________________________
2 Home Address Direccioacuten Residencial _____________________________________________________________________________________________________
3 City Ciudad _______________________________________ State Estado _____________________ Zip Coacutedigo Postal ______________________________
4 Date of Injury Fecha de la lesioacuten (accidente) ________________________________ Time of Injury Hora en que ocurrioacute ____________am ___________pm
5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente _______________________________________________________
_______________________________________________________________________________________________________________________________________
6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada ____________________________________________________________
_______________________________________________________________________________________________________________________________________
7 Social Security Number Nuacutemero de Seguro Social del Empleado _______________________________________________________________________________
8 Check if you agree to receive notices about your claim by email only Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electroacutenico Employeersquos e-mail _____________________________________ Correo electroacutenico del empleado __________________________________________ You will receive benefit notices by regular mail if you do not choose or your claims administrator does not offer an electronic service option Usted recibiraacute notificaciones de beneficios por correo ordinario si usted no escoge o su administrador de reclamos no le ofrece una opcioacuten de servicio electroacutenico
9 Signature of employee Firma del empleado ________________________________________________________________________________________________
Employermdashcomplete this section and see note below Empleadormdashcomplete esta seccioacuten y note la notacioacuten abajo
10 Name of employer Nombre del empleador ________________________________________________________________________________________________
11 Address Direccioacuten __________________________________________________________________________________________________________________
12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente ___________________________________________
13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten ______________________________________________________
14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador_____________________________________________________
15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros _______________
_______________________________________________________________________________________________________________________________________
16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro___________________________________________________________________________________
17 Signature of employer representative Firma del representante del empleador ____________________________________________________________________
18 Title Tiacutetulo _________________________________________ 19 Telephone Teleacutefono ___________________________________________________________
Employer You are required to date this form and provide copies to your insurer or claims administrator and to the employee dependent or representative who filed the claim within one working day of receipt of the form from the employee
SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY
Empleador Se requiere que Ud feche esta forma y que proveacutea copias a su compantildeiacutea de seguros administrador de reclamos o dependienterepresentante de reclamos y al empleado que hayan presentado esta peticioacuten dentro del plazo de un diacutea haacutebil desde el momento de haber sido recibida la forma del empleado
EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD
Employer copyCopia del Empleador Employee copyCopia del Empleado Claims AdministratorAdministrador de Reclamos Temporary ReceiptRecibo del Empleado
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
State of California Please complete in triplicate (type if possible) Mail two copies toEMPLOYERS REPORT OF OCCUPATIONAL INJURY OR ILLNESS
Any person who makes or causes to be made anyknowingly false or fraudulent material statement ormaterial representation for the purpose of obtaining ordenying workers compensation benefits or payments isguilty of a felony
California law requires employers to report within five days of knowledge every occupational injury or illness which results in lost time beyond thedate of the incident OR requires medical treatment beyond first aid If an employee subsequently dies as a result of a previously reported injury orillness the employer must file within five days of knowledge an amended report indicating death In addition every serious injury illness or deathmust be reported immediately by telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health
EMPLOYER
6 TYPE OF EMPLOYERCity School DistrictPrivate CountyState Other Govt Specify
17 DATE OF EMPLOYERS KNOWLEDGE NOTICE OFINJURYILLNESS (mmddyy)
18 DATE EMPLOYEE WAS PROVIDED CLAIM FORM15 PAID FULL DAYS WAGES FOR DATE OF SEX16 SALARY BEING CONTINUEDNJURY OR LAST FORM (mmddyy)Yes NoDAY WORKED Yes No19 SPECIFIC INJURYILLNESS AND PART OF BODY AFFECTED MEDICAL DIAGNOSIS if available eg Second degree burns on right arm tendonitis on left elbow lead poisoning AGE
INJURY
21 ON EMPLOYERS PREMISES20a COUNTY20 LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Number Street City Zip)
Yes No
22 DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED eg Shipping department machine shop 23 Other Workers injured or ill in this eventYes No
OR
ILLNESS
PART OF BODY
ATTENTION This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possiblewhile the information is being used for occupational safety and health purposes See CCR Title 8 1430029 (b)(6)-(10) amp 1430035(b)(2)(E)2Note Shaded boxes indicate confidential employee information as listed in CCR Title 8 1430035(b)(2)(E)2
EMPLOYEE
35 OCCUPATION (Regular job title NO initials abbreviations or numbers)
37b UNDER WHAT CLASS CODE OF YOURPOLICY WHERE WAGES ASSIGNED
37a EMPLOYMENT STATUS37 EMPLOYEE USUALLY WORKSregular full-time
part-time
EXTENT OF INJURY
total weekly hoursdays per weekhours per daytemporary seasonal
39 OTHER PAYMENTS NOT REPORTED AS WAGESISALARY (eg tips meals overtime bonuses etc)38 GROSS WAGESSALARYper$ Yes No
Date (mmddyy)Signature amp TitleCompleted By (type or print)
bull Confidential information may be disclosed only to the employee former employee or their personal representative (CCR Title 8 1430035) to others for the purpose of processing a workers compensation or other insuranceclaim and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 1430030) CCR Title 8 1430040 requires provision upon request to certain state andfederal workplace safety agencies
FORM 5020 (Rev7) June 2002 FILING OF THIS FORM IS NOT AN ADMISSION OF LIABILITY
OSHA CASE NO
FATALITY
1 FIRM NAME Ia Policy Number
2 MAILING ADDRESS (Number Street City Zip) 2a Phone Number
3 LOCATION if different from Mailing Address (Number Street City and Zip) 3a Location Code
4 NATURE OF BUSINESS eg Painting contractor wholesale grocer sawmill hotel etc 5 State unemployment insurance acctno
Please do not usethis column
CASE NUMBER
OWNERSHIP
INDUSTRY
OCCUPATION7 DATE OF INJURY ONSET OF ILLNESS(mmddyy)
8 TIME INJURYILLNESS OCCURREDPMAM
9 TIME EMPLOYEE BEGAN WORKPMAM
10 IF EMPLOYEE DIED DATE OF DEATH (mmddyy)
1 1 UNABLE TO WORK FOR AT LEAST ONEFULL DAY AFTER DATE OF INJURY
Yes No
12 DATE LAST WORKED (mmddyy) 13 DATE RETURNED TO WORK (mmddyy) 14 IF STILL OFF WORK CHECK THIS BOX
DAILY HOURS
DAYS PER WEEK
WEEKLY HOURS
WEEKLY WAGE
COUNTY
NATURE OF INJURY
24 EQUIPMENT MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED eg Acetylene welding torch farm tractor scaffold
25 SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED eg Welding seams of metal forms loading boxes onto truck
26 HOW INJURYILLNESS OCCURRED DESCRIBE SEQUENCE OF EVENTS SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURYIILLNESS eg Worker stepped back to inspect work and slipped on scrap material As he fell he brushed against fresh weld and burned right hand USE SEPARATE SHEET IF NECESSARY
SOURCE
EVENT
SECONDARY SOURCE
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss
control materials relate only to the insurability of the workplace and the premiums to be charged Any support material provided
or recommendations (whether submitted in writing or not) are provided to help you reduce your potential for losses relative to
the coverage we afford under the insurance contract They do not address and are not intended to address every loss potential
statute violation or exception to good practice
SUPERVISOR ACCIDENT REPORT
The purpose of the Supervisorrsquos Accident Report is to determine both the immediate and root causes of an
incident that resulted in injury or potential to cause injury By root cause we mean the underlying reasons
for the accident For example the immediate cause of a slip and fall may be water on the floor but the root
or underlying cause could be maintenance issues resulting in a leaking water pipe or the method used to
carry water that resulted in spilled water Once the immediate and root causes of the accident have been
determined preventative measures can be identified and effectively instituted
To be effective the review must be fact-finding not fault finding
It is the immediate manager or supervisor who has the prominent role in conducting the accident review
The manager or supervisor should
1) collect the facts
2) determine the sequence of events
3) determine the immediate cause(s)
4) determine the ldquorootrdquo or underlying cause(s)
5) identify controls or action(s) that will help prevent reoccurrence
6) take or assign corrective action
7) follow-up to ensure that corrective action is effective
8) reserve any evidence for recovery purposes and
9) take photorsquos of any defects amp accident scene
All accidents should be reviewed promptly regardless of their severity Promptness of the review is essential
since conditions at the accident scene change and witnesses are likely to forget with time Promptness in
checking the scene assures employees that management is highly concerned for their well-being
Accident reports should be submitted within 24 hours of the first notice of the incident using the attached
form to report to senior management what is being done to prevent a reoccurrence
For additional information in accident review methods please refer to the CalOSHA website
httpwwwdircagovdoshdosh_publicationsIIPPhtml9
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
WORKERrsquoS COMPENSATION FRAUD IS A FELONY REPORT SUSPECTED FRAUD TO THE INSURANCE COMPANY
WH
O W
AS
IN
VO
LV
ED
W
HA
T H
AP
PE
NE
D
Injured Employee Name DOB
Department Job Title Phone Number
Work Address City State Zip
Task being performed at time of incident
Date of Incident Time of Incident AM PM Date Reported
Shift AM PM Night Other Was the Employee on Overtime Yes No Time Shift Commenced
Incident Location (specific area)
Witness(es) to Incident
Description of event
Describe property damage associated with the incident
ALL ITEMS MUST BE FULLY ANSWERED
use additional pages as needed
Supervisorrsquos Accident Report
ConfidentialFor internal company use only
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice 1
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
WH
Y D
ID I
T H
AP
PE
N
VE
RIF
ICA
TIO
N T
HA
T A
CT
ION
HA
S B
EE
N T
AK
EN
Date Person(s) Completing Form
Employeersquos Supervisor
Who was immediately in charge at the time of injury
Please explain training that was provided to perform the task and when it was last provided
Is there a written procedure describing how to safely perform the task Explain
Equipment involved Type Model No Manufacturer
Immediate Cause
ROOT CAUSE ANALYSIS ndash Why the incident occurred
Corrective Action
Describe action that has been taken and what actions remain to be taken List interim or temporary actions Any delayed actions should be
explained
Supervisors Signature Date
Safety Committee Review Date
Verification that correction is complete
Senior Manager Date
2
Form provided by Care West Insurance Company
PO Box 2710 Rocklin CA 95610 - Phone 877-625-6566 - Fax 209-574-2839
Disclaimer Loss Control and safety is the responsibility of your Companys management Our surveys support services and loss control materials relate
only to the insurability of the workplace and the premiums to be charged Any support material provided or recommendations (whether submitted in
writing or not) are provided to help you reduce your potential for losses relative to the coverage we afford under the insurance contract They do not
address and are not intended to address every loss potential statute violation or exception to good practice
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
WORKERSrsquo COMPENSATION FRAUD
Care West Claims Management
Administered by Pegasus
PO Box 5038
Modesto CA 95352-5038
Phone (209) 574-2800 Fax (209) 574-2839
Workersrsquo Compensation Fraud
Definition Workersrsquo Compensation fraud laws make it a felony for anyone to file a false or fraudulent
statement or to submit a false report or any other document for the purpose of obtaining or denying
Workers Compensation benefits Anyone caught performing these illegal acts will be prosecuted If
convicted the person can face up to 5 years in prison and or up to a $150000 fine
Statement
In an effort to keep our workers compensation program fair for all we must guard against fraud Filing a
Workers Compensation claim means you were injured on the job and not elsewhere This means you
have no doubt that your injury occurred on the job
Furthermore you are required by California State Law to provide the true facts Information that is false
inaccurate withheld or exaggerated could constitute Workers Compensation fraud
Each filed claim is reviewed and may be fully investigated If any of the facts are found to be false
inaccurate withheld or exaggerated disciplinary action including termination will be taken Legal action
may also be taken We bring these matters to your attention because Workersrsquo Compensation fraud is
against the law
I have read the statement above and understand that Workers Compensation fraud is against the law
________________________________
Signature
________________________________
Print Full Name
________________________________
Date
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
AUTHORIZATION TO RELEASE INFORMATION
Patient Name ______________________________________________________________________________
Patient Address ____________________________________________________________________________
Date of Birth ______________________________________________________________________________
Social Security No _________________________ Medical Record No ________________________________
I _______________________________________ (workerpatient full name please print) hereby authorize and request
disclosure of all protected information to aid Care West Insurance Company and its agents attorneys and subsidiaries in
establishing the liability nature and extent of a claim for injuries or disabilities and to establish benefits expenses
compensation and damages I expressly request that the designated record custodian of all covered entities under
HIPAA disclose full and complete protected medical information to the organization identified including the following
All medical records meaning every page in my record including but not limited to office notes
room treatment clinical charts reports progress notes nursersquos notes social worker records
treatment plans admission records test results questionnaires photographs videorsquos
telephone messages and records received from other medical providers
All physical occupational and rehab requests consultation and progress notes
All Medicare or Medicaid records
All pharmacy and prescription records
All lab histology cytology pathology immunohistochemistry records radiology reports and
films NCM MRI Ct EMG Cardiac Cath videos CDs films reels and reports
All psychological or psychiatric carevisit records for any visit or mental health care
All employment personnel or wage records
Specific consent to any and all HIV and HEP C medical and HIV and HEP C related information
under the conditions of this form
This consent is subject to revocation by the undersigned in writing at any time by notifying the above
requestor except to the extent that action has been taken in reliance herein This authorization shall
terminate at the date of resolution of my claim absent express revocation
I understand I have a right as a patient to review the disclosed information by requesting it from the
organization providing it
I hereby release all parties from any and all legal liability that may arise from the release of this information to
the party(s) named above This is informed consent for the release of records A photocopy of this original
shall be deemed as valid to the original
Patient Signature _________________________________________________ Date ___________________
Patient Name (please print) ___________________________________
Patient Representative ____________________________ Relationship _____________ Date ____________
Representative Name (please print) ________________________________________
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
WAGE STATEMENT
EMPLOYEE _______________________________ EMPLOYER ____________________________________
DATE EMPLOYED _________________________
EMPLOYEErsquoS WORK IS _____TEMPORARYON CALL _____PART-TIME _____REGULAR
(CHECK ONE) _____INTRODUCTORY _____FULL-TIME
IF EMPLOYEE IS A NEW HIRE AND THERE ARE NO WAGES AVAILABLE PLEASE INDICATE AVERAGE NUMBER OF HOURS EXPECTED TO WORK
RATE OF PAY__________________PER HOUR OF HOURS WORKED__________________PER WEEK
DATE OF LAST PAY INCREASE ____________________________ IF THE EMPLOYEE IS DUE FOR A PAY INCREASE PLEASE SPECIFICY EFFECTIVE DATE AND AMOUNT
____________________________________________________
FROM DATE TO DATE GROSS EARNINGS
COMMENTS
$$$$$$$$$$$$$$$$$$$$$$$$$$
TOTAL DAYS TOTAL $
REMARKS _____________________________________________________________________________________
I CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT
SIGNED ___________________________________________ DATED _____________________________
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
DECLINATION OF WORKERSrsquo COMPENSATION BENEFITS (MEDICAL TREATMENT)
I ________________________________ understand that I am entitled to Workersrsquo (employee)
Compensation benefits examination andor treatment under my Employerrsquos Workersrsquo Compensation Policy
I reported a work related incidentinjury on ______________________ As a result (date)
of the incident I injured my ____________________________________________________ (body part)
while performing ________________________________________________ job task
I understand this declination is a voluntary decision and does not waive my rights under Workersrsquo Compensation Benefits as set forth by the State of California
I agree to notify my employer immediately if in the future I feel medical treatment for this injury becomes necessary and will I want to seek medical treatment
I was also provided a DWC-1 form
___________________________________ Employee Signature
___________________________________ Authorized Employer Signature
__________________________ Date
Form 0902-02
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
Verbal
Descriptor Scale
Wong-Baker
Facial Grimace
Scale
Activity
Tolerance Scale
Spanish
UNIVERSAL PAIN ASSESSMENT TOOL
This tool is intended to help assess pain
Use the faces or behavioral observations to interpret expressed pain intensity
Please circle your pain level
Por favor circule su nivel de dolor
__________________________________________________________________________
Claimant Signature (Firma Reclamante) Date (Fecha)
Alert Smiling No Humor
Serious Flat
Furrowed Brow
Pursed Lips Breath
Holding
Wrinkled Nose
Raised upper lip
Rapid Breathing
Slow blink
Open mouth
Eyes closed
Moaning
Crying
NO PAIN CAN BE IGNORED INTERFERES WITH TASKS
INTERFERES WITH CONCENTRATION
INTERFERES WITH BASIC NEEDS
BED REST REQUIRED
SIN DOLOR PUEDE SER IGNORADA
INTERFIERE CON TAREAS
INTERFIERE CON CONCENTRACIOacuteN
INTERFIERE CON NECESIDADES
BAacuteSICAS
CAMA RESTO SE REQUIERE
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form
33
Please mark on the picture and checkbox the body part injured as reported (Marque por favor en la photographia yen la caja la parte del cuerpo lastimado)
LEFT SIDE (Lado Izquierdo) RIGHT SIDE (Lado Derecbo) FRONT (Frente) BACK (Espalda) HEAD lCabeza) FACE (Cara) NECK (Cuello) SHOULDER (Hombro) ARM (Brazo) WRIST (Muiieca) HAND(Mano) FINGER(S) (Dedo(s)) CHEST (Pecho) ABDOMEN (Abdomen) RIBS (Costillas) HIPS (Cadera) BUTTOCKS (Nalea) THIGH (Muslo) KNEE lRodilla) LEG lPieroa) ANKLE (Tobillo) FOOT (Pie) OTHER (Otra Parte)
Claimant Signature (Firma)
(Vista Frontal) FRONT VIEW
derecho) right
(izquierda) left
Date (Fecba)
(Vista Posterior) BACK VIEW
(izquierda) left
derecho) right
- DWCForm1 revised 10815pdf
-
- DWCForm7FinalClean
- ClaimForm2010
-
- DWC7 Notice to Employeespdf
-
- DWC 7 Cover Sheet - Copy
- DWC 7 Notice to Employees Poster 112016 - Copy
-
- Please_complete_in_tripli
- OSHA_CASE_NO
- CheckBox1 Off
- 1_FIRM_NAME
- Ia_Policy_Number
- 2_MAILING_ADDRESS_Number
- 2a_Phone_Number
- 3_LOCATION_ifdifferent_fr
- 3aLocation_Code
- 4_NATURE_OF_BUSINESS_eg_P
- 6 Off
- Other_Govt_Specify
- 7_DATE_OF_INJURY__ONSET_O
- 8_AM2
- 7_DATE_OF_INJURY__ONSET_1
- AM1
- 10_IF_EMPLOYEE_DIED_DATE
- 11 Off
- 13_DATE_RETURNED_TO_WORK
- CheckBox2 Off
- 18I_PAID_FULL_DAYS_WAGES_FO Off
- 16_SALARY_BEING_CONTINUED Off
- 17_DATE_OF_EMPLOYERS_KNOW
- 19_SPECIFIC_INJURYILLNESS
- 20_LOCATION_WHERE_EVENT_O
- 20a_COUNTY
- 22_DEPARTMENT_WHERE_EVENT
- 21_ON_EMPLOYERS_PREMISES Off
- 23 Off
- 24_EQUIPMENT_MATERIALS_AN
- 25_SPECIFIC_ACTIVITY_THE
- 27_Phone_411h
- 29 Off
- 29_HOSP_TA_ZED_AS_AN_NAl
- Jills_Phone_No
- 30_EMPLO_CC_NAME
- 31_SOC_A_SECUPITi_NUMBER
- 32_DATE_OF_I_PTH_mm_ddio
- 33_HOME_ADDRESS_IN_be_Sto
- 33a_PHONE_NUMBER
- 34 Off
- 35_OCC_UPAT_ON_Ppqj_a_on
- 36_DATE_OF_H_RE_mmiddlyy
- E
- hours_per_day
- days_per_week1
- FillText1
- per
- 37a Off
- Completed_By_type_or_prin
- 39 Off
- 8_pm
- 12_DATE_RETURNED_TO_WORK
- 18_DATE_EMPLOYEE_PROVIDED
- 26_HOW_INJURY_ILLNESS
- 27_name _address_of_physician
- 37b-under-chat-class-code
- 5_stae_unemployment
- 27 27 Name and address of physician (number street city zip)
- 27a 27a Phone Number
- 28 28 Hospitalized as an inpatient overnight
- 28yes_text If yes then name and address of hospital (number street city zip)
- 28no No
- 28yes Yes
- 29yes Yes
- 29no No
- 29text 29 Employee treated in emergency room
- 28a 28a Phone Number
- 30 30 EMPLOYEE NAME
- 31 31 SOCIAL SECURITY NUMBER
- 32 32 DATE OF BIRTH (mmddyy)
- 33 33 HOME ADDRESS (Number Street CityZip)
- 33a 33a PHONE NUMBER
- 36 36 DATE OF HIRE (mmddyy)
- 34sex 34 SEX
- 34male Male
- 34female Female
- 1 Name Nombre
- Todays Date Fecha de Hoy
- 2 Home Address Direccioacuten Residencial
- 3 City Ciudad
- State Estado
- Zip Coacutedigo Postal
- 4 Date of Injury Fecha de la lesioacuten accidente
- Time of Injury Hora en que ocurrioacute
- am
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 1
- 5 Address and description of where injury happened Direccioacutenlugar doacutende occurioacute el accidente 2
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 1
- 6 Describe injury and part of body affected Describa la lesioacuten y parte del cuerpo afectada 2
- 7 Social Security Number Nuacutemero de Seguro Social del Empleado
- 8
-
- Check Box Off
- Check Box Spanish Off
-
- electroacutenico Employees email
- Correo electroacutenico del empleado
- 10 Name of employer Nombre del empleador
- 11 Address Direccioacuten
- 12 Date employer first knew of injury Fecha en que el empleador supo por primera vez de la lesioacuten o accidente
- 13 Date claim form was provided to employee Fecha en que se le entregoacute al empleado la peticioacuten
- 14 Date employer received claim form Fecha en que el empleado devolvioacute la peticioacuten al empleador
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 1
- 15 Name and address of insurance carrier or adjusting agency Nombre y direccioacuten de la compantildeiacutea de seguros o agencia adminstradora de seguros 2
- 16 Insurance Policy Number El nuacutemero de la poacuteliza de Seguro
- 18 Title Tiacutetulo
- 19 Telephone Teleacutefono
- Employer copyCopia del Empleador Off
- Employee copyCopia del Empleado Off
- Claims AdministratorAdministrador de Reclamos Off
- Temporary ReceiptRecibo del Empleado Off
- Clear Form