Workers Compensation Medical/Loss Time
If you are injured while at work and are planning to seek immediate medical attention or end up seeking medical attention please make sure to read all the information below.
- Please make sure that you have noted on the Accident Report Form that you are going to a Dr. to be seen for your work related injury.
o Also contact the Human Resources office at 781-283-3303 to notify us prior to being seen as some Dr.’s offices require pre-approval from our workers compensation company for your visit.
- If you are going to be out due to a work related injury:
o you need to make sure to have a note from your treating physician putting you out of work
o please have this note faxed to the Human Resources office at 781-283-3663 - If you are managing your own care for your work related injury:
o please make sure that both Meadowbrook TPA Associates and the Human Resources Office receive updates from your treating physician
o The treating physician may fax us at: Meadowbrook – 978-681-1987 Human Resources – 781-283-3663
- Once your physician has cleared you to return to work:
o Fax the return to work information to both Meadowbrook TPA Associates and the Human Resources Office.
o If there are restrictions with your return to work the Human Resources Office will go over these restrictions with your department to make sure they are able to accommodate the restriction and the Human Resources Office will contact your directly to confirm your return to work date.
- If you would like to make changes or stop any of your Wellesley College benefits while you are out of work, please contact our Benefits Specialist at 781-283-2212. - Please make sure to provide your Dr.’s offices with our workers compensation
company information below. You will receive a confirmation letter from
Meadowbrook when your claim has been approved which will include a claim number to provide to your Dr.’s office for billing purposes.
o Any bills that you receive directly should either be forwarded by you to Meadowbrook or you should contact your physician’s office to have them redirect the bills to Meadowbrook.
Meadowbrook TPA Associates 10 New England Business Center Suite 303
Andover, MA 01810 Main # - 978-691-2470 Fax # - 978-681-1987
- While you are out due to your work related injury you must make arrangements with the Human Resources Office to pay for the employee portion of your health and/or dental benefits, if applicable.
Benefits Payment Options:
Please check off which option you would prefer and return this form to the Human Resources office by fax, mail or drop off.
_____ Please supplement my time with sick/vacation/personal
time so that I am receiving full pay while I am out due to my work related injury.
_____ Please supplement my time with sick/vacation/personal time to cover my health/dental benefits.
_____ I do not wish to supplement my time and please bill me for my portion of my health/dental benefits.
**If you run out of time to continue to supplement we will then start to bill you for your portion of your health and/or dental benefits. If you have questions/concerns about paying for your benefits please contact our Benefits Specialist at 781-283-2212.
Important - Please Read: If the Human Resources Office does not receive this form or hear from you directly then you will go into an unpaid status and will be automatically billed for you benefits.
Please feel free to call us at 781-283-3303 with any other questions or concerns.
______________________________________ ________________
Employee Signature Date
______________________________________ Print Name
E m ployee Informa tion Incident Detail Notes/ Comments Page 1 of 1
Accident Reporting Form
Phone Number Employee Name Job Title Date of Birth Reported To Shift
Current Mailing Address
Yes Date of Hire Supervisor Home Phone Incident Description Department Incident Date
Employee Signature (if available):
Location where injured
Medical Treatment Required:
Date: Cell Phone Injury Description No Address Treating Physician/Facility Side of Body
Body Part Type of Injury (i.e. sprain/strain, bruise)
Will you lose any time due to this injury? First day out of work:
Today’s Date:
Yes No Witnesses
Please put in any additional information here:
When completed please fax form to the Human Resources office at 781‐283‐3663 and to the Health and Safety Department at 781‐283‐3643.
Our Worker's Compensation provider is Occupational Health Center/ Beth Israel Deaconess Hospital/ Needham Campus. We welcome the opportunity in working with Occupational Health Center. For more information, please call HR X3303
Rehabilitation
Physical therapy Hand therapy Work conditioning Repetitive strain injuries Occupational therapy Treatment
Services
Occupational Health Center at
Beth Israel Deaconess Hospital / Needham Campus
Specialty Services
Second opinions
Functional capacity exams (FCE) Independent medical evaluation Case Management
Chemical exposure Partnership for a Healthy Workplace
148 Chestnut Street Needham, MA 02492 (781) 453-3041
Urgent Care Lacerations Contusions Strains/sprains Minor fractures Eye injuries Health Education and Promotion Instructional Series CPR First aid Cholesterol Smoking Cessation Stress Management Screening Clinics Breast exams Cardiac risk factors Cholesterol Glucose Podiatry Prostate Skin cancer Lectures Elder issues Exercise Heart health Infectious disease Nutrition Parenting Women's health
How to Access The Occupational Health Center
*Monday through Friday, 8:00 a.m. - 4:30 p.m. (Clinic hours)
Contact Shannon Stark at (781) 453-3041; FAX: (781) 453-5782
Emergency Department
4:30 p.m. - 8:00 a.m. (Weekdays, weekends and holidays) (781)453-5400 *** See attached map ***
From North, West and East
Take Route 128 South to Exit 19B. Proceed on Highland Avenue for approximately 1.5 miles Bear right onto Chapel Street. Cross Great Plain Avenue onto Chestnut Street. Follow Chestnut Street for one
block. The Hospital is on the left, just past the Fire Station and the intersection with School Street From the South:
Take Route 128 to Exit 17. Turn right onto Route 135. Proceed approx 1.6 miles along Dedham Avenue (Route 135). Bear left onto School Street and follow to end at Chestnut Street. Take left onto
Chestnut Street.
Public Transportation:
MBTA Commuter Rail-Needham Line, stops at the Needham Junction station, Monday through Saturday. The Hospital is located mile east of the Needham Junction station on Chestnut Street. MBTA Bus Line, Route 59, also provides transportation service (Monday through Saturday) from Watertown Square, via Newtonville, to Beth Israel Deaconess Hospital-Needham Campus on Chestnut Street.
Prevention and Assessment Services Other Immunizations/vaccinations Job analysis
Medical surveillance (OSHA requirements) Ergonomics-lab and office
Body mechanics training Bloodbome pathogens training
Exams
Annual physicals DOT physicals Drug & alcohol Fit-for-duty Hearing Pre-placement Pulmonary function
Starting from: 106 Central Street, Wellesley, MA 02482 Arriving at: 148 Chestnut Street, Needhan, MA 02492
Directions Distance
Total Est. Time: 11 minutes Total Est. Distance: 4.00 miles 1: Start out going EAST on CENTRAL ST / MA-135 toward CROSS ST.
Continue to follow MA-135.
0.5 miles 2: Turn RIGHT onto WELLESLEY AVE / MA-135. <0.1 miles
3: Turn SLIGHT RIGHT onto BROOK ST. 0.9 miles
4: Turn RIGHT onto GREAT PLAIN AVE / MA-135 E. 2.3 miles
5: Turn RIGHT onto CHESTNUT ST. 0.1 miles
6: End at 148 Chestnut St
Needham, MA 02492-2505, US
