Workers Compensation employee packet


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Workers’ Compensation Packet Content

Arlington County Government


of Treating Clinics, Physicians & Hospitals

PMA Express Scripts


Eligibility Form

Arlington County Workers Compensation

Disability Certificate

Disability Note &

Mileage Reimbursement


Form 5 – Claim for Benefits





The Panel of Physicians and Virginia Law. The following clinics, hospitals, and physicians are the current official Workers' Compensation panel and must be used for treatment in Workers' Compensation Claims. Refusal to use this panel may subject you to paying the full cost of medical treatment. Pursuant to Va. Code 65.2-603, by choosing a physician from this panel, you are choosing a treating physician for your injury or occupational illness. Your treating physician will be responsible for the medical management of your case, including any referrals to specialists for related treatment. Once you have selected your treating physician, you may not change physicians without prior approval from the Claim Adjuster or the Workers’ Compensation Administrator.

Following are descriptions of the process of receiving initial medical care, depending on the type of need:

Urgent Care. For your urgent care needs that are not considered life threatening (e.g., a back sprain or broken leg), please select one of the authorized clinics,where you will receive immediate care. The list of clinics have physicians specializing in occupational injuries. You are only authorized one visit at the urgent care facility, there are exceptions to this rule, such as removal of sutures etc, however, the urgent care doctor can not assume care of your condition if additional treatment is required. If you need additional medical services in a specialty area, the clinic physician will refer you to an appropriate specialist from the panel. If a specialty is not listed, please contact PMA for further information. For urgent care needs outside of clinic hours, please select a hospital emergency room from the panel.

Emergency Care. For any potentially life-threatening injury or situation, please go immediately to the nearest hospital emergency room. Emergency room physicians are not eligible as treating physicians for continuing care. You are only authorized one visit at an emergency care facility, and there are exceptions to this rule, such as admittance to the hospital for a life threatening injury. If the emergency room physician indicates you need additional or continuing care once stable, you must select a treating or specialist physician from the panel.

Occupational illnesses and Non-Urgent, Non-Emergency Care. If you have non-urgent care needs or believe you may have an occupational disease, please file your claim with PMA before selecting a physician from the panel in order to receive assistance in selecting the appropriate physician. You may select an appropriate physician directly from the panel without a referral.






MidAtlantic Urgent Care Clarendon 3301 Wilson Blvd Arlington, VA 22201 Phone: 703-243-6720 Open: 9am – 9pm M-F 9 am – 6pm Sat 10am – 5pm Sun

Simplicity Urgent Care 3263 Columbia Pike Arlington, VA 22204 Phone: 703-746-0111 Open – 8am – 8pm M-F 10am – 4pm Sat-Sun

Virginia Hospital Center 1701 N. George Mason Drive

Arlington, VA 22205 Phone: 703-558-5000 Express Care – Open 11am – 11pm, 7 Days

Hospital Open – 24/7

Walk-In Medical Care Bina Kololgi, MD 12011 Lee Jackson Memorial Hwy #102 Fairfax, Virginia 22033 Phone: 703-385-8378 Open - 7am – 9pm M-Sun

Arlington Urgent Care 601 South Carlin Springs Road

Arlington, VA 22024 Phone: 703-578-2350 Open: 24 hours, 7 days a week

Inova Alexandria Occupational Health Center 4320 Seminary Road Alexandria, VA 22314 Phone: 703-504-6600 Open: 7am – 4pm, M-F -AND-

Inova Alexandria Hospital Phone: 703-504-3000 Open: 24 /7


Steven Hughes, MD SPINE – BACK

Commonwealth Orthopaedics 4401 Ford Ave, # 303, Alex VA; Or 8320 Old Courthouse Rd #100 Vienna, VA Main Phone: 703-810-5212 Web: Angela M. Santini, MD SPINE-NECK/BACK/ EXTREMITIES

Lansdowne Medical Pavilion 19450 Deerfield Avenue #175 Leesburg, VA 20176 Phone: 703-858-5454 Web: Barry Saffran, DPM FOOT/ANKLE SPECIALIST Center for Foot & Ankle PC 3020 Hamaker Court, # 201 Fairfax, VA 22031 Phone: 703-207-0073 Web: Steven Neufeld, MD Matthew M. Buchanan, MD FOOT/ ANKLE SPECIALIST Orthopedic Foot & Ankle Center 2922 Telestar Court Falls Church, VA 22042 Phone: 703-769-8420 Web: Sarah Pettrone, MD HAND/WRIST SPECIALIST Commonwealth Orthopaedics 8320 Old Courthouse Rd # 100 Vienna, VA 22182 703-810-5225 Also Office in Reston Web: Lonnie Davis, MD BACK ONLY 2841 Hartland Road # 401 Falls Church, VA 22043 Phone: 703-848-0800 Ramesh Chandra, MD

UPPER & LOWER EXTREMITY Center for Orhopaedics & Sports Med 8230 Boone Blvd # 200 Vienna, VA 22182 Phone: 703-848-0800, or 108 Elden Street #15 Herndon, VA 20170 Phone: 703-464-0664 Web: Derek Ochiai, MD Eric Guidi, MD Robert Nirschl, MD Clay Wellborn, MD Andrew B. Wolff, MD Cassie Root, MD EXTREMITIES /HAND/HIP Nirschl Orthopaedic Center 1715 N. George Mason Dr #504 Arlington, VA 22205 Phone: 703-525-2200 Web: Wiemi Douoguih, MD David Johnson, MD ANKLE/FOOT/KNEE/SPINE SHOULDER/HAND/ELBOW

Orthopedic Surgery at MedStar of WHC 106 Irving St, South Tower

#215 NW Washington, DC 20010 Phone: 202-877-6000 Christopher Annunziata, MD Charles Lefton, MD Frank Pettrone, MD SHOULDER/KNEE/ELBOW SPINE/WRIST Commonwealth Orthopaedics 1635 N. George Mason Dr #310 Arlington, VA 22205 Phone: 703-810-5215 Web:


Physical therapy & Sports Medicine Institute – 5 Locations Alexandria PH: 703-205-0278 Falls Church PH: 703-205-1233 Fairfax PH: 703-273-4616 Herndon PH: 703-464-0554 Leesburg PH: 703-726-9702 Web:



James Tozzi, MD


106 Irving St, South Tower # 215 NW Washington, DC 20010 Phone: 202-291-9266

Arthur Kobrine, MD

NEUROSURGERY – NECK /BACK 2440 M. Street, #315 NW Washington, DC 20037 Phone: 202-293-7136 Stuart Stark, MD David W. Always MD Mahan Chehrenama, DO NEUROLOGY & HEADACHES 4660 Kenmore Avenue, # 900 Alexandria, VA 22304 Phone: 703-212-0700 Web: CARDIOLOGY PULMONARY Antonio Parente, MD Michael Notarianni, MD Timothy P. Farrell, MD Warren S. Levy, MD CARDIOVASCULAR GROUP 1625 N. George Mason Dr #414 Arlington, VA 22205 Phone: 703-524-7202 Robert Shor, MD CARDIOVASCULAR GROUP 1860 Towncenter Dr. # 120 Reston, VA 20190 Phone: 703-437-5977 Carey Marder, MD CARDIOVASCULAR GROUP 130 Park St., #100 Vienna, VA 22180 Phone: 703-281-1265 Steven M. Zimmet, MD PULMONARY MEDICINE 1440 S. Joyce St.,#126 Arlington, VA 22202 Phone: 703-521-6662

Northern VA Pulmonary & Critical Care Associates 1715 N. George Mason Dr # 106 Arlington, VA Ph: 703-276-1916 -AND- 3289 Woodburn Rd. # 350 Annandale, VA Ph: 703-641-8616


James T. Mayes, III, MD FACS J.R. Salameh, MD FACS GENERAL SURGEONS SURGICAL ASSOCIATES AT VHC 1625 N. George Mason Dr. #334 Arlington, VA 22205 Phone: 703-717-4250 Harry N. Snyder, OD N. VA DRS OF OPTOMETRY Loehmann’s Plaza 7263-E Arlington Blvd Falls Church, VA 22042 Phone: 703-573-1200 Theodora Vroustouris, OD N. VA DRS OF OPTOMETRY Crystal City Mall – Concourse 1800 S. Bell #18-19 Arlington, VA 22202 Phone: 703-413-1400 Jerome Spechler, DDS 3610 Forest Dr. Alexandria, VA 22302 Phone: 703-578-4221 Michael R. Abindin, MD 6355 Walker Lane # 308 Alexandria, VA 22310 Phone: 703-313-7700 Scott A. McQuiston, DDS 5350 Shawnee Rd # 310 Alexandria, VA 22312 Phone: 703-354-0111 Zafar Iqbal, MD 1715 N. George Mason Dr #202 Arlington, VA 22205 Phone: 703-522-0137



6305 Castle Place, Suite 1-D Falls Church, VA 22044 Phone: 703-534-5500 Jeffery Jay, Ph.D PSYCHOLOGIST 4601 Connecticut Ave. #5 NW Washington, DC 20008 Phone: 202-362-0063 John W. Wires, Ph.D PSYCHOLOGY/ PSYCHIATRY 3959 Pender Dr # 320 Fairfax, VA 22030 Phone: 703-352-3822 Charles Burt, Ph.D PSYCHOLOGIST 1800 Michael Faraday Dr #206 Reston, VA 20190 Phone: 703-471-4123 Ronald E. Smith, Ph.D PSYCHIATRIST 140 Little Falls St. #100 Falls Church , VA 22046 Phone: 202-338-6543


EMPLOYEE DESCRIBE THE INCIDENT DETAILS/ ACCIDENT: (Include part of the Body/ Type of Injury)


History of previous injuries or conditions: Is the injury consistent with the accident described by employee: Yes ( ) No ( ) Undetermined ( )

Diagnosis or Impression of Medical Condition(s):

Recommendations for treatment as it relates to the work-related condition(s): Specify Type/Duration/Frequency


Specify Medication Prescribed: Will medication prevent employee from working, using equipment, machinery or driving? Yes ( ) No ( )


Employee May Return toRegular work Yes ( ) No ( )

** If Employee is unable to return to Regular Work, Arlington County can accommodate alternative work with restrictions**

Employee May Return to Modified Light Duty Work with Restrictions Yes ( ) No ( ) Please List Specific Restrictions, (Example: No Lifting > 10 lbs; or No prolonged standing)

How long are Work Restrictions expected to last? Start Date: ______________ End Date/ Resume Regular






PHYSICIAN’S PRINTED NAME ___________________________________TELEPHONE NUMBER______________


Forward Bills/ Reports: PMA Medical Bills & Records PO Box 5231 Janesville, WI 53547-5231



The top portion must be completed by the employee. It is the employee’s responsibility to ensure the physician completes the bottom portion of this form and to return the completed form to the supervisor and the claim adjuster. Failure to submit the completed certificate will prevent use of Disability Leave (DB) Benefits.

***** FAX TO CLAIM ADJUSTER @ 804-967-5694 *****

Employee: _________________________________________Claim No.: _________________________Date of Accident_______________ Job Title: _____________________________________________________Supervisor Name/Phone:________________________________



FAX TO CLAIM ADJUSTER 804-967-5694 or 800-432-9762

The Disability Note is completed by the employee and signed by the supervisor. It is used to document and record intermittent hours of lost time used, rather than whole days taken out of work as a result of a medical appointment relating to treatment for the work related injury, such as time spent for physical therapy, completion of

diagnostic test, or office visit with the doctor.

Employees are responsible for faxing the completed form to the Claim Adjuster at the

PMA Company so that disability leave or temporary partial disability can be processed properly. If the disability leave cannot be verified, it will be changed to sick leave.

Mileage Reimbursement is a benefit provided to injured employees. Employees can be reimbursed for travel at a rate of _55.5_cents per mile for medical visits and

treatment related to work injuries as well as visits relating to vocational rehabilitation services. If employees do not complete the departure and destination address, the mileage reimbursement cannot be processed.

EMPLOYEE NAME______________________________________DATE OF ACCIDENT _____________

CLAIM NUMBER: Date Departure (Home or Work Address) Destination (Medical Provider Address) Disability Hours Purpose of Visit Round trip Mileage Example 1/3/05 2055 N. 15th St. Arl Va Zip Code 22201

Grovedale Prof Center 6166 Fuller Ct, Alex Va Zip Code 22310 3 hours Physical Therapy 11+ 11 = 22 mi

Employee Signature ___________________________________________________Date___________ Supervisor Signature__________________________________________________Date___________


Virginia Workers’ Compensation Commission


Even if you have already received benefits from Arlington County or Insurer, you must files a claim with the Virginia Workers’ Compensation Commission (VWCC) in order to protect your right to benefits under Virginia Law and obtain an FUTURE MEDICAL LIFETIME AWARD.

To file a claim for benefits, follow the directions on the VWCC web site link: Click on the link - Claim for Benefits


You may also request a future medical lifetime award electronically through the VWCC web site link below under heading Claimants:Download theWebFile Guide for

Claimants. You may also call 1-877-664-2566 if you have questions.


In the event you have been unable to resolve an issue with the Third Party Administrator and the Risk Management Office, an employee may request review of the dispute by the VWCC. The Form 5’s are also used to settle a dispute and disagreements such as denial of treatment or denial of claim or any other benefit you feel should be covered under workers’ compensation. When requesting for a review by the VWCC, please attach any supporting documentation to validate your claim.

The Form 5s are also used when applying for other benefits, such as permanent partial disability, death benefits for a spouse who has received benefits under workers’

compensation, or even payment of specific medical bills. These type of issues should be addressed with the Third Party Administrator or the Risk Management Office prior to submitting a form 5 to the VWCC, because in most cases, the County will voluntarily pay an employee for permanent partial disability, death benefits or medical bills. A hearing is necessary if no resolution has been accomplished through any other means.

If you are unable to download the Form from the Virginia Commission site, you may email at to request the form.





For Employees of Arlington County Virginia


Arlington County is committed to providing each

injured employee fair, courteous, prompt medical

services and a timely determination of claim.

We strive to ensure employees obtain information regarding their

rights and responsibilities when injured on the job as well as any

applicable benefits for which they are eligible under the Virginia

Workers’ Compensation Act and County Policy



Table of Contents



Section 1: Definitions


Section 2: Administration: How to Report an Injury or Illness


Supervisor’s Responsibility


Employee’s Responsibility


Claim Adjuster’s Responsibility


Section 3: Medical Treatment


How to select a panel physician


Employee - Physician Relationship


Prescription Program


Medical Supplies and Durable Medical Equipment


MRI , CT Scans & Other Diagnostic Tests


Section 4: Disability Leave and Compensation for Lost Wages 10

Disability Leave


Medical Bills


Section 5: Explanation of County and State Required Forms 11

Section 6: Workers’ Compensation Benefits Under the Act


Section 7: Bloodborne Pathogens & Exposures


Procedure for post exposure follow-up evaluation



Section 1: Definitions

Accident - An event that takes place without one’s foresight or expectation, a sudden and unexpected event or mishap causing injury to a person.

ACG - Arlington County Government and employer.

Act - Workers’ Compensation Act or the Virginia Code of rules and regulations

governing injured workers, employers and medical providers. The Act established the Virginia Workers’ Compensation Commission to oversee the proper operations of employer workers’ compensation programs.

Average Weekly Wage (AWW) - Earnings paid in the position worked at the

time of injury during 52 weeks immediately preceding the date of injury divided by 52.

Award - Receipt of an approved Notice from the Virginia Workers’ Compensation

Commission granting benefits or other relief under the Act.

Change in Condition - A change in physical condition of the employee as well

as any change in the conditions under which compensation was awarded which would affect the right to, amount of, or duration of compensation.

Claims Representative - Claims adjuster assigned to process the employee’s

claim for workers’ compensation benefits and lost wages. The adjuster shall also determine whether or not the injury is covered under the Act.

Commission (VWCC) - The Virginia Workers’ Compensation Commission; the

state governing authority.

Compensable - A Workers’ Compensation claim for benefits that is covered

under the Virginia Workers Compensation Act.

Disability - The inability (whether physical and/or mental) of an eligible employee

to perform all of the assigned duties of the regular occupation with ACG. The determination of disability shall be made by the claim representative or adjuster based on the available medical evidence.

Delivery Code - The department/division location to which the employee is

assigned. This information is located on the employee pay stub.

Doctor or Physician - A medical practitioner licensed to practice within a

specified jurisdiction. The medical doctor must be a part of the ACG Panel of Physicians.

EAR (Employer’s Accident Report) - Formerly FRA (First Report of Accident).

A form that provides notice to the Virginia Workers’ Compensation Commission (VWCC) that an injury or occupational illness has occurred at the workplace.

Eligible Employee - An employee who receives monetary compensation from

Arlington County Government.


Employee Workers’ Compensation Pack - A packet of forms and documents to include: 1) County Panel of Physicians, 2) Notice and Selection of Physician Form, 3) Disability Certificate, 4) Disability Note, 5) TMESYS Prescription Eligibility Form/Provider List, 6) Employees Workers’ Compensation Booklet, and 7) Claim for Benefits– Form 5.

Injury by Accident - 1) the injury occurs suddenly at a particular time and place

and upon a particular occasion, 2) it was caused by an identifiable incident or sudden precipitating event, 3) it resulted in an obvious mechanical or structural change in the human body, and 4) there is a causal connection between the incident and the bodily change.

Maximum Medical Improvement (MMI) - When an employee’s medical

condition has returned to pre-injury level or has reached a level of resolution or plateau with no further appreciable improvement to gain.

Occupational Injury or Illness - An injury or illness covered by a state or federal

workers’ compensation law.

Permanent Impairment - Permanent residual loss of use of a scheduled body

part. Scheduled means a specified period of time compensation is paid for a certain body part.

Pre-injury Status - When an employee’s medical condition has resolved, and

the employee has returned to prior injury baseline status without any residual loss of use.

Subrogation - To recover damages, relief or remedy from the negligent third


Third Party Administrator (TPA) - shall mean the Schaffer Companies,

responsible for workers’ compensation claims administration for all Arlington County personnel.

Waiting Period - First seven (7) calendar days period before wages are paid

from workers’ compensation or that consideration is provided for non-taxable wages.


Section 2: How to Report an Injury or Illness

Supervisor ...

1. Directs all employees to provide notification of an on-the-job injury immediately.

2. Obtains all pertinent information from the injured employee regarding the accident details and should document information in the event the claims adjuster requests written information. The Supervisors Report for Workers’ Compensation form is no longer required.

3. Reports claims through telereporting center, calling 1-866-252-4654, or through the online claim service at, within 24 hours from the date notified of the work accident or injury. Once reported a confirmation number is assigned.

4. Provides to the TPA the correct Payroll Delivery Code (also known as Location Number), and job title of the employee to ensure proper loss run reporting.

5. Provides the employee with an Employee Workers’ Compensation Pack to include the following documents and forms: The County Panel of Physicians; Notice and Selection of Physician Form; Disability Certificate; Disability Note; TMESYS Prescription Eligibility Form/Provider List; Employees Workers’ Compensation Booklet; Claim For Benefits Form 5. 6. Assists the employee with transportation to an urgent care facility if medical

treatment is necessary, or if warranted calls 911 for emergencies.

7. Reports all bloodborne pathogen exposure incidents through telereporting or online service and follows the County’s bloodborne pathogen policy. For possible exposure to Tuberculosis, the employee should be referred to the County’s Occupational Health Unit for testing at (703) 228-4813 or an Urgent Care Center if Occupational Health is unavailable. (More details on page 14)

8. Assists the claims adjuster by identifying physical and functional requirements of the job for the physician.

9. Collaborates with claims adjuster, healthcare providers in managing disabilities by creating temporary alternate duty (TAD) to accommodate disability.

10. Promotes Safety Training and Awareness and helps reduce the incidence of injury and occupational illnesses.

Employee ...

1. Reports accident to supervisor immediately.

2. Seeks necessary medical treatment initially at urgent care or, if life threatening, calls 911. (Once medical treatment has been initiated, the urgent care physician or emergency room physician will provide a referral to a specialist if follow-up treatment is required. The specialist must be selected from the County Panel of Physicians.)


3. Is required to seek treatment with a County Panel Medical Provider for his/her workers’ compensation injury or illness. ( Employees may not change doctors without approval from the claims adjuster )

4. Obtains the Employees Workers’ Compensation Pack from the supervisor.

5. Cooperates with the claims adjuster. Once the injury has been reported as a workers’ compensation claim, the employee will be contacted by the claims adjuster who will take a statement, verify information, explain rights and responsibilities, and answer any questions. ( If the adjuster is unable to reach the employee the adjuster will notify the employee in writing to contact the adjuster. If no contact is established , an employee’s claim will be closed without determination, disallowing any further benefits. )

6. Completes the Notice and Selection of Physician Form once a Specialist is selected and forwards this information to the claims adjuster.

7. Completes the top portion of the Disability Certificate during each medical office visit to a physician and ensures completion of the bottom portion of the Disability Certificate by the physician.

8. Returns the completed Disability Certificate to his/her supervisor and the claims adjuster to ensure eligibility for the Disability Leave benefit. (If the employee requires time off work to attend physical therapy or take test,

etc., the employee must complete the Disability Note to document the

hours away from work to ensure eligibility for the Disability Leave benefit. ) 9. Notifies the supervisor of all medical appointments related to the

work injury and the ability to perform work as outlined by physician.

10. Files a Claim for Benefits ( Form 5) with the Workers’ Compensation Commission within two years from the date of accident, otherwise any right to benefits may be lost. Claims for an occupational disease must be filed within two years from the date the doctor tells the employee the disease is work-related, or within five years from the date the employee was last exposed to the work condition causing the disease, whichever is sooner.

11. Notifies supervisor and claim adjuster of any change of phone number or resident address.

12. Completes required Employer and Commission Forms. Failure to cooperate or complete required forms may result in delay or denial of workers’ compensation benefits.

13. Seeks and accepts employment if released to return to work.

Claims Adjuster...

1. Attends to the employee claim needs, explaining the workers’ compensation process, forms, benefits and rights; answering any questions and addressing any problems that occur.


2. Ensures employees obtain necessary and reasonable treatment for the work related injury.

3. Facilitates and monitors medical treatment, conferring with the treating physician and supervisor to coordinate a return to work as soon as medically possible.

4. Makes claim determinations, processes bills and reimbursements. 5. Verifies and documents disability leave and processes workers’

compensation payments once disability leave expires.

Section 3: Medical Treatment

How to Select a Panel Physician

Today, doctors are usually very specialized in their medical practices. Below is a general outline of the types of physicians who treat workers’ compensation injuries or illnesses.

Cardiologist - Specializes in diagnosis and treatment of heart conditions.

General Internist - Diagnoses and provides treatment for diseases and injuries

to the internal organs, such as stomach, kidneys, digestive tract.

Occupational Medicine - These are the front-line physicians specializing in

work accident injuries and where employees are directed initially after reporting a work accident. They are affiliated with the Urgent Ccare and Emergency Room Facilities on the Panel. They treat strains, sprains, lacerations, contusions, as well as minor and major fractures of the lower and upper extremities. If follow-up care is required, this physician will provide a referral for a specialty type such as a neurologist or orthopedist.

Orthopedist or Orthopedic Surgeon - Treatment of bones or joints,

specializing in the back, neck, knee, hand and shoulder.

Psychiatrist/Psychologist - These specialists are similar in that both treat

mental and behavioral problems. Psychiatrists prescribe medication while psychologists cannot.

Physiatrist/Physical Medicine & Rehabilitation - These specialists are similar

to orthopedic physicians in that they treat injuries to the bone and joints, as well as managing chronic pain. They do not perform surgery.

Pulmonologist - Specializes indiagnosis and treatment of lung conditions.

Neurologist - Treats injuries and diseases affecting the nerves. This physician

is highly trained in testing and does not perform surgery.


Neurosurgeon - Specializes in diagnosis and treatment of the brain, head, neck, back and neurological conditions relating to these areas.

Employee-Physician Relationship

It is important to know the treating physician plays a key role in the facilitation of a workers’ compensation claim. The physician decides whether an injury or symptoms occurred on the job based on the history provided by the employee and the physician’s clinical examination. As such, it is important for an employee to give an accurate history of the injury details during the initial visit. It is also important to provide a complete and accurate history of any prior related medical condition (s).

In addition, the physician selected to treat the work-related condition make decisions about whether or not an employee is entitled to further medical treatment, the ability to work regular or modified light duty, and creates treatment plan to return an employee to pre-injury status or a level of maximum medical improvement. Once an employee has reached a level of maximum medical improvement, the physician will determine whether there is any permanent impairment or loss of residual use arising out of the injury.

The treating physician is required to provide written reports and periodic medical reports to the claim adjuster to explain the employee’s condition and prognosis. Disputes may arise when an employee is in disagreement with the treating physician. When this occurs the employee should: 1) discuss any disagreement with the doctor ; 2) If dissatisfied with the physician response on a particular issue or dispute, contact the adjuster and discuss the problem to see whether the adjuster can resolve the matter; 3) If no resolution occurs, contact the County Workers’ Compensation Administrator for assistance.

Prescription Service

Prescriptions are covered at 100% of cost through the workers’ compensation program. To receive this benefit, employees must use the Express Scripts Prescription Form for Workers’ Compensation. Employees may not use their personal health insurance coverage for services related to the workers’

compensation claim. To obtain medications, employees must complete the form to include name , date of birth, ID # or SS # and address. Once completed,

provide the Express Scripts form to the pharmacist at the participating pharmacy. The Eligible Pharmacy vendors are on page 2 or back side of form. Most of the common pharmacies are listed. Additional pharmacy listings are available by contacting the Express Scripts Patient Care Contact Center at 800-945-5951.


If an employee requires assistance or experiences problems with a particular participating pharmacy call the Patient Care Contact Center. If an employee needs to make a pharmacy change he/she will need to complete another prescription form or have the pharmacy representative contact Express Scripts at the Express Help Desk 888-786-9640.

Medical Supplies and Durable Medical Equipment

If the physician writes a prescription for durable medical equipment, the employee must contact the claim adjuster and receive approval. The adjuster will contact a vendor and order the equipment or supplies as prescribed by the physician.

MRI, CT Scans & Other Diagnostic Test

If the physician has written a prescription for a diagnostic test, the employee must contact the claim adjuster to receive approval. The physician has to provide a letter of medical necessity for such items. The claim adjuster will contact a vendor and schedule the appointment for the employee.

Section 4: Disability and Compensation for Lost Wages

Disability Leave

Lost wages resulting from a work related injury or an occupational disease are non-taxable; however, employees are required to submit Disability Certificates or Notes substantiating their absence for wages to qualify as non-taxable. If the employee does not submit the Certificate or Note, disability leave will not be paid and any earnings will be taxable. Arlington County provides up to 720 hours of disability leave as a benefit to permanent employees whose occupational injuries or illnesses are determined payable pursuant to the provisions of the Virginia Workers' Compensation Act. Disability leave is a continuation of regular earnings and allows the continuation of payroll deductions while the employee recuperates from the injury or illness. If an employee has exhausted the 720 hour disability leave and is still not released to return to work, the employee may apply for an extension of disability leave or the employee receives Temporary Total Disability (TTD) benefits or Temporary Partial Disability (TPD) benefits. These wage loss benefits are mailed bi-weekly to the employee’s home address. Temporary employees are not entitled to disability leave but are eligible for TTD or TPD.


Medical bills

Submitto the claim adjuster at the PMA Customer Service, PO Box 5231, Janesville, WI 53547-5231.

Section 5 : Explanation of County and State Workers’

Compensation Forms

Arlington County forms are available on the intranet. Supervisors and

employees are expected to complete forms to ensure processing of eligible benefits. If an employee requires assistance with completing forms, the claims adjuster is available. Failure to properly complete forms may delay or result in denial of benefits.

Workers’ Compensation Medical Authorization Release Form

An employee’s health and medical information is considered sensitive and private and is afforded protection under the law.

However, in certain instances the adjuster may be unable to make a determination of claim and will require additional information from the private physician, an individual or entity. (e.g. hospitals, prior employers, other insurance companies, etc.) Workers compensation is not a covered entity under the Health Insurance Portability and Accountability Act (HIPAA),; and therefore HIPAA procedural requirements do not apply.

Workers’ Compensation Disability Certificate - This form is required from the

treating physician indicating the employee’s ability to perform work, or what particular work restrictions may apply while recuperating from the work injury or occupational illness. The two-part form requires completion of the top portion by the employee and the bottom portion by the physician. The employee must ensure the form is returned to the supervisor and submitted to the claims adjuster within 7 calendar days.

Disability Note & Mileage Reimbursement Form - This form is required if you

are requesting disability leave for intermittent periods of time away from work. Employees utilize this form when attending physical therapy appointments, physician visits and testing related to the work injury. Employees are also allowed travel reimbursement for medical visits and treatment related to the work injury as well as visits relating to vocational rehabilitation services.

State forms from the Workers’ Compensation Commission aid employees and

employers in understanding the rights and benefits under the Act as well as facilitate processes related to the resolution of claim.

Employer’s Accident Report (Form 3) - formerly called the First Report of

Accident for employees injured on the job, this form is generated as a result of the telereporting or online reporting of an incident. The claims adjuster files the original form with the Commission and provides a copy to the supervisor and the employee.


Report of Minor Injuries (Form 45-A) - this form is filed by the claims adjuster to report minor injuries which do not involve: 1) time loss of more than 7 days; 2) more than $1,000 in medical cost; and 3) any fatality, permanent impairment or disfigurement.

Agreement to Pay Benefits (Form 4) - formerly called Memorandum of

Agreement. This is a required form when the employee’s claim has been accepted and the employee has lost more than 7 days from work. The form must have the signature of the employer or its representative and the employee. The employee must sign and return this form to the claim adjuster to sign and submit the original green form to the Commission. There are additional supplemental forms if benefits terminate and the employee is again eligible to receive additional compensation. The adjuster provides notification when other forms must be filed with the Commission.

Termination of Wage Loss Award (Form 46) - formerly called Agreed

Statement of Fact. This form is required when the employee : 1) has been released to return to work and is no longer eligible for wage loss;

2) elects to receive other compensation such as retirement benefits, or Social Security, etc., 3)receives other monetary compensation. Termination of Wage Loss Award does not preclude future medical benefits or compensation entitlements.

Claim for Benefits ( Form 5) - This form is used to protect the employee

rights to future medical and indemnity benefits under the Act. Employees must file this form within two years from the date of accident or any right to benefits may be lost. Claims for an occupational disease must be filed within two years from the date the doctor tells the employee the disease is work related, or within five years from the date the employee was last exposed to the work condition causing the disease, whichever is sooner.

The Form 5 is also used to request a formal hearing to address disputes relating to compensation of Temporary Disability, Temporary Partial Disability, and Permanent Partial Disability etc., or any other issue arising which cannot be resolved through any other means

Section 6: Workers’ Compensation Benefits Under the


If a workers’ compensation claim has been accepted under the Workers’ Compensation Act, an employee may be entitled to the following benefits:

Wage Replacement (temporary total or partial)

While temporarily unable to perform any work, an employee is entitled to 2/3 of his or her gross average weekly wage up to a set maximum weekly limit. There must be seven (7) days of disability before benefits are payable. However, if disabled for more than three weeks, the employee receives payment for the first seven days. Benefits cannot exceed 500 weeks unless the person is totally and permanently disabled. If the injured employee cannot return to regular work and is given a light duty job at a lower wage, benefits are 2/3 of the difference between the pre-injury wage and the current pay up to the maximum weekly limit.



Lifetime Medical Benefits

Medical expenses for conditions caused by the accident or occupational disease are payable for as long as necessary, reasonable and related, provided a claim was filed by the employee within the required time period. The employee must cooperate with medical treatment or benefits may be suspended. Medical bills should be sent to the Schaffer Companies.

Permanent Partial Impairment

Separate benefits are payable for the permanent loss of use of a body part such as an arm, leg, finger, or eye. Vision and hearing loss, as well as disfigurement may also be compensated. This does not include the back, neck or body as a whole. Benefits are for a specific number of weeks depending on the percentage of loss. The employee can receive these benefits while working if maximum medical improvement has been reached.

Permanent and Total Disability

Lifetime wage benefits may be payable if an individual loses both hands, arms, feet, legs, eyes, in the same accident, or is paralyzed or disabled from a severe brain injury.

Death Benefits

A surviving spouse, children under 18, children under 23 enrolled full time in an accredited educational institution, parents in destitute circumstances or other qualifying dependents may be entitled to wage loss benefits. Death benefits include funeral expenses not to exceed $10,000 and transportation cost of $1,000.

Cost of Living Increase

A person receiving temporary total, permanent total or death benefits is entitled to cost of living increases effective October 1 of each year. Cost of living increases must be specifically requested by the employee.

Vocational Rehabilitation

Employees who are released to light duty work must prove that they are actively looking for a light duty job, even if they expect to return to their regular job. Employees must accept all suitable positions offered, or risk suspension of benefits.

Section 7 : Bloodborne Pathogens & Exposures

The supervisor must report all Bloodborne pathogen exposure incidents to the third party administrator reporting service and follow the County Bloodborne pathogen policy.


When an employee is exposed to Bloodborne pathogens, they are to report to : Infectious Disease Physicians, Inc., Doctors Ellen Kessler and Allan Morrison, 3289 Woodburn Road, Suite 200, Annandale, VA 22003. The Infectious Disease Office has 24 hour coverage and the phone

number is 703– 560-7900.



Employee: Cleans exposed area and immediately reports the incident to the

supervisor .

Supervisor: Calls in incident or completes on line record as reported by

the employee and directs the employee for treatment.

Physician: Provides professional medical determination of whether

an actual exposure has occurred. Treatment is available 24/7. The

physician will notify the employee (and source, if applicable) of test results and necessary medical follow-up. The physician will provide counseling, as necessary.

If it is determined the exposure occurred and the source individual refuses blood testing, laboratory work, and or analysis of the blood sample, immediately notify the County Workers’ Compensation Unit and the public safety agency or the employee may petition the general district court of the city or county in which the person resides or resided pursuant to the Arlington County Bloodborne Pathogens Exposure Control Plan.

If an employee refuses post-exposure evaluation or follow-up treatment, the physician will obtain an employee signed Letter of Declination and forward a copy to the County Workers’ Compensation Unit.

If a positive test results requiring further medical care and maintenance treatment, the infectious disease physician will provide the employee with the County physician panel and direct the employee to select a treating physician. A written report of the initial evaluation and recommended treatment are forwarded to the claim adjuster.

Occupational Health Unit serves as a consultant to the Workers’ Compensation

Unit and the Infectious Disease consulting physicians. The occupational health staff is available to employees and supervisors for questions regarding medical follow-up once the employee has received initial care from the consulting physicians.

For possible exposure to Tuberculosis, the employee should be referred to the County’s Occupational Health Unit (703) 228-4813 or if unavailable, an

urgent care center for testing.



For Claim Information

Reporting A Claim

Online at

Option # 1– Go to AC Source intranet >HR Benefits Tab >

Click Risk Management Link > Click Workers’

Compensation Link,

or directly @

PMA Management Co.

1-800-572-7624 at Extension 5606 or 5682

Monday - Friday 9AM - 5PM

FAX: 804-967-5694

EXPRESS SCRIPTS Prescription Helpline


Send Medical Bills To:

PMA — Medical Bill & Records

PO Box 5231

Janesville, WI 53547-5231

County Workers’ Compensation Unit

Zee Cabbagestalk — 703-228-3473

VA Workers’ Compensation Commission

877-664-2566 (Toll free)