THIS FORM MUST BE ENTIRELY COMPLETED IN ORDER TO PROCESS YOUR CLAIM
COBB COUNTY SCHOOL DISTRICTEMPLOYEE REPORT OF WORK RELATED ACCIDENT
(770) 590-4520 FOR WORKERS’ COMPENSATION (678) 594-8266
Office Fax
Employee _____________________________________ SS# __________________ DOB _________ Age ____ Sex ____ Home Address_____________________________________________________________________________________ City _______________________________State ______Zip ________ Tel#_____________________________________ School/Dept _________________________________________ Employee Occupation ___________________________ Accident Date _____________ Time _______ Date Reported_________ Accident Location _______________________ Body Part(s) Injured _______________________________________ Describe the Accident ______________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Witnesses_____________________________________________________ Tel#__________________________
*ATTENTION: IF MEDICAL TREATMENT IS SOUGHT IT MUST BE WITH AN APPROVED PANEL PHYSICIAN*
Medical Treatment? ___ Yes ___ No Name of Treating Doctor/Clinic: _________________________________________ Taken via Ambulance? __ Yes __ No Left Work Due to Injury? __ Yes __No First Day Out of Work_______________ Primary Care Physician Name_________________________________________ Tel#_____________________________
Prior Medical Treatment?
Have you had prior injury or condition to injured body part(s) Yes___ No____ If yes, explain______________________ __________________________________________________________________________________________________
How Can Future Accidents Be Prevented? (Mark all that apply)
Employee Training _____ Proper Use of Equipment___ Improve Task Procedures _____ Improve Work Area _____ Equipment Correction _____ Removal of Hazard _____ Use of Personal Protective Equipment _____ Provide Hazard Warning _____ Enforce Policy/Rule _____ Other_____ Explain: ___________________________________________ _________________________________________________________________________________________________ Employee suggestion(s) for preventing similar accidents: __________________________________________________ Supervisor suggestion(s) for preventing similar incidents: _______________________________________________________
Employee’s Signature ____________________________________________ Date________________________________
Supervisor’s Signature________________________________________ Tel#_____________________ Date_______________
NOTE: CONTACT RISK MANAGEMENT IMMEDIATELY IF MEDICAL TREATMENT IS REQUIRED.
PLEASE SUBMIT SIGNED SUPERVISOR’S REPORT AND THE SIGNED MEDICAL RELEASE WITHIN 48 HOURS.
Cobb County School District
Risk Management Department
Office (770) 590-4520
Fax (678) 594-8266
MEDICAL RELEASE AUTHORIZATION FORM
Please submit signed medical release form, as well as the Supervisor’s Report of Injury, to the
Risk Management Department within 48 hours of injury. Keep a copy for your site files.
7/2015
Release of Medical Information: I authorize the release to my employer and Workers’
Compensation Company all records relevant to my disability and my claim for disability or
Workers’ Compensation benefits, including, but not limited to, medical diagnosis, prognosis,
treatment and periods of hospitalization. It is understood that the Risk Management
Department will use the information to verify my disability and determine my eligibility of
appropriate benefits. This authorization applies to physicians and other health care
providers, hospitals, clinics, insurance companies, Workers’ Compensation carriers and
organizations administering benefit programs. This authorization will remain in effect
throughout my claim for Workers’ Compensation benefits. A photocopy of this authorization
will be as valid as the original.
Panel of Physicians: I have received a copy of the Bill of Rights for the Injured Worker, as
well as, the Traditional Panel of Physicians.
Employee’s Signature____________________________________ Date______________
Please Print Name __________________________________________________________
OFFICIAL NOTICE
This business operates under the Georgia Workers’ Compensation Law.
WORKERS MUST REPORT ALL ACCIDENTS IMMEDIATELY TO THE EMPLOYER BY ADVISING THE EMPLOYER PERSONALLY, AN AGENT, REPRESENTATIVE, BOSS, SUPERVISOR OR FOREMAN.
If a worker is injured at work, the employer shall pay medical and rehabilitation expenses within the limits of the law. In some cases the employer will also pay a part of the worker’s lost wages. Work Injuries and occupational diseases should be reported in writing whenever possible. The worker may lose the right to receive compensation if an accident is not reported within 30 days (see O.C.G.A. § 34-9-80).
The employer will supply free of charge, upon request, a form for reporting accidents and will also furnish, free of charge, information about workers’ compensation. The employer will also furnish to the employee, upon request, copies of board forms on file with the employer pertaining to an
employee’s claim.
A worker injured on the job must select a doctor from the list below. The minimum panel shall consist of at least six physicians, including an orthopedic surgeon with no more than two physicians from industrial clinics (see O.C.G.A. § 34-9-201). Further, this panel shall include one minority physician, whenever feasible (see Rule 201 for definition of minority physician). The Board may grant exceptions to the required size of the panel where it is demonstrated that more than four physicians are not reasonably accessible. One change of doctor, from the list, may be made without permission. Further changes require the permission of the employer or the State Board of Workers’ Compensation.
State Board of Workers’ Compensation 270 Peachtree Street, N.W. Atlanta, Georgia 30303 404-656-3818 or 1-800-533-0682 http://www.sbwc.georgia.gov OCCUPATIONAL CLINICS_
WELLSTAR U.S. HEALTH WORKS
3805 Cherokee St., Kennesaw (770) 426-5665 470 Franklin Rd. SE, Ste. 103, Marietta 3600 Sandy Plains Rd., Marietta (770) 977-4547 (770) 428-8900
2890 Delk Rd., Marietta (770) 955-8620
4480 N. Cooper Lake Rd., Smyrna (770) 333-1300 4525 Fulton Industrial Blvd. SW, Atlanta 4550 Cobb Pkwy, Acworth (770) 917-8140 (404) 691-4999
_ORTHOPAEDICS_
FREDERICK WENER, M.D. CHRISTOPHER EDWARDS, M.D. (Orthopaedic Surgery & Sports Medicine) (Orthopaedic Spine Surgeon) 3969 S. Cobb Drive Ste.108 1810 White Circle Smyrna, GA 30080 Marietta, GA 30066
(770) 436-0041 Appointment Line: (404) 265-6701 THE CENTER FOR ORTHOPAEDICS & SPORTS MEDICINE
RICK HAMMESFAHR, M.D (Leg, Knee, Ankle, Foot)
&
CRAIG WEIL, M.D. (Shoulder, Arm, Hand, Wrist)
1211 Johnson Ferry Road Marietta, GA 30068
(770) 565-0011 PODIATRIST NATHAN SCHWARTZ, DPM ANKLE & FOOT CENTERS OF GEORGIA
861 Windy Hill Road Smyrna, GA 30080
(404) 434-7078
The employer/insured providing coverage for this business under the Workers’ Compensation Law is: COBB COUNTY SCHOOL DISTRICT
P.O. BOX 1088, MARIETTA, GA 30061 (770) 426-3357
IF YOU HAVE QUESTIONS PLEASE CONTACT THE STATE BOARD OF WORKERS’ COMPENSATION AT 404-656-3818 OR 1-800-533-0682 OR VISIT http://www.sbwc.georgia.gov
Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties of up to $10,000.00 per violation (O.C.G.A. §34-9-18 and § 34-9-19)
Carlisle Medical/RESTAT Workers’ Compensation Prescription Information
Making a Difference
1-800-553-1783 M-F 10am-6pm CST
Please present this information to any participating pharmacy for prescription processing
Employee Name: (Please Print) _________________________________________________________
Social Security Number (used as Member ID) : ___ ___ ___ - ___ ___ - ___ ___ ___ ___
Date of Birth: ___________________________________
Date of Injury: __________________________________
Plan/Group Number: W 908
Member Number: Employee’s SS # ___ ___ ___ - ___ ___ - ___ ___ ___ ___
(plus the injury date, NO dashes MM/DD/YY)
RESTAT Bin Number: 600471
Person Code: 000
Our employee has been injured in a work related accident. Please use the information above to process prescriptions for Cobb
County School District. If you have questions, please call our office. Thank You.
Melanie Mabry, Medical Claims Adjuster
Office ~ 770-590-4520
COBB COUNTY SCHOOL DISTRICT
Worker’s Compensation ~ Risk Management
Mileage Reimbursement Form
Fax # 678-594-8266
EMPLOYEE NAME: ________________________________________
DATE
STARTING ADDRESS
(use complete address with city/zip)
DESTINATION~
ADDRESS
(Ie: PT, Dr Appt ,etc.-use complete address with city/zip )
MILES
Roundtrip
One Year Deadline With Regard to Medical Expenses
Section 4 of SB 233 also creates O.C.G.A. 34-9-200(c)(4), which provides for a one year deadline with regard to medical expenses. It states that, “Notwithstanding any other provisions of this subsection, if the employee or the provider of healthcare goods or services fails to submit its charges to the employer or its workers’ compensation insurer within one year of the date of service of the issuance of such goods or services, then the provider is deemed to have waived its right to collect such charges from the employer, its workers’ compensation insurer, and the employee.”
