For Your Convenience
U.S. HealthWorks Specializes in Treating On-the-Job Injuries
Employer:
Quil Ceda Village
Employee Name: _____________________________________________ Date: ___________________
Service Requested: ___
Injury Treatment
___
Audiogram
___
Respiratory Questionnaire Review – Fax to Dixie Walker @ 425-259-0301
___
Respiratory Clearance Physical
___
Bloodborne Pathogen – Source Testing
___
Other ______________________________________________________________
IF QUESTIONS, CALL: Melissa Cavender Phone: 360-716-5067 (Office)/360-722-1592 (Cell)
8/20/13
PLEASE BRING
PHOTO ID
Benefits Of Using U.S. HealthWorks Medical Clinics
for Treatment of On-The-Job Injuries
Walk-In Care (Appointments Available Upon Request)
Limits Out-Of-Pocket Expense for Workers
Xray, Orthopedic Supplies (Crutches, Braces, Etc.) For Your Convenience
Open Extended Hours, Including Evenings & Weekends
Easy Referral to Physical Therapy and Specialists If Medically Necessary
Industrial Insurance Paperwork Completed & Mailed Within 24 Hours
Please be aware U.S. HealthWorks Medical Clinic is not an emergency room.
If you have a life-threatening illness or injury, call 911.
U.S. HealthWorks, Everett
3726 Broadway, Everett (425-267-0299)
(Open Monday-Friday 7 a.m. to 6 p.m.)
DRIVING INSTRUCTIONS FROM QUILCEDA VILLAGE: Take I-5 South. Take 41
stStreet Exit and turn right
onto 41
stStreet. Take the first right onto Colby Avenue and turn right at 37
thStreet. Turn right at Broadway.
U.S. HealthWorks will be on right (just before Aqua Sox Stadium).
U.S. HealthWorks, Lynnwood
4320 196
th
Street S.W., Lynnwood (425-774-8758)
(Open Monday-Friday 8 a.m. to 8 p.m. & Saturday-Sunday 9 a.m. to 6 p.m.)
DRIVING INSTRUCTIONS FROM QUILCEDA VILLAGE: Take I-5 South. Take Exit #181 and merge onto 196
thStreet S.W going west. Turn left at light (40
thAvenue West) and turn right at 198
thStreet S.W. Go to 44
thAvenue West and turn right. U.S. HealthWorks is on the right side of the road, just past Wells Fargo Bank.
QUILCEDA VILLAGE
8802 27th AVE. N.E. TULALIP, WA. 98271
How to Process Your Workers' Compensation Insurance Claim
The following steps shall be followed to insure your claim is processed in a timely
manner:
1. Immediately report your injury to your immediate supervisor and pick up a Medical
Injury Packet from the Health and Safety Department. Contact Melissa Cavender at
360-716-5067 or 360-722-1592.
2. Seek medical attention at US Health Works (map inside packet).
IMPORTANT: Your employer/Tribal First reserves the right to direct your care to a
provider of their choice. Otherwise, your claim may not be approved.
3. Have the attending physician complete the Physicians Initial Report included in this
packet. Your attending physician needs to also complete the Released for Work
Authorization with the activity the worker can actively do and the plans for worker’s
progress portions of the Activity Prescription Form. (You cannot return to work without
this form) This form is your responsibility to be returned to the Health and Safety
Department and it will be forwarded to Tribal First along with your Medical Injury
Report.
4. Complete the upper portion of the Medical Injury Report included in this packet. This
is required to be completed within 48 hours of the injury. Return the completed form to
the Health and Safety Department, in which they will complete the bottom portion of the
accident report and forward to Tribal First.
5. As soon as Tribal First receives your completed accident report, your claim will be
processed and a claim number assigned. If Tribal First does not receive a completed
form, time loss, and/or medical benefits
will not be provided.
If you have any questions regarding the completion of this packet, please contact Health
and Safety Department. You may contact the claims examiner, if needed for additional
information at Tribal First at 1-877-777-8039.
QUILCEDA VILLAGE MEDICAL REPORT
Maintenance ____ Broadband ____ TDS______ QCV________Utilites
TEAM MEMBER COMPLETE THIS SECTION
Team Members Name ____________________________________ Date of Accident ___________________
Job Title & Dept.__________________________________________ Home Ph # _______________________
Time of Accident ______________ Any Witness(s)? ______________________________________________
Nature of Injuries? __________________________________________________________________________
Please Refer to Guidelines if you will be Seeking Medical Treatment.
Describe the accident (include job site, conditions, ie. wet floor, icy steps, rain, etc., how many workers involved on
same project)
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Team Member Signature _____________________________________ Date ____________________
SUPERVISOR COMPLETE THIS SECTION
Supervisor Name __________________________________Date Notified_________ Time Notified ________
Did You Witness the Accident?
Yes or No
(circle one)
Who Reported to You? _________________________
Time Reported to Safety? _________________ By Who? _______________________ U A? ____________
Team Members Start Time_________ End Time ________ Days Off_________________________________
What Caused this Accident?
What action was taken to prevent reoccurrence?
_________________________________________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________
Supervisors Signature ____________________________________________ Date _____________________
Please Check Box Below
Non ~ Job Related Incident
Job Related Incident ~ Packet Given
Supervisor Is Not Requesting a Doctors Release
Supervisor requesting Team Member to bring in doctors release to Heath and Safety Department.
MAIL TO TRIBAL FIRST
PHYSICIAN’S INITIAL REPORT
1. NAME OF EMPLOYER
Quil Ceda Village
PATIENT INFORMATION
ADDRESS
8802 27
thAve NE
2. NAME OF INJURED WORKER: FIRST MIDDLE LAST 3. WORKER'S TELEPHONE #CITY
Tulalip
STATEWA
ZIP98271
4. MAILING ADDRESS 5. SOCIAL SECURITY NUMBERNAME OF EMPLOYER'S SERVICE REPRESENTATIVE
Tribal First
4160 6
th
Ave SE, Suite 207
Lacey, WA 98503
6. CITY 7. STATE 8. ZIP 9. DATE OF BIRTH (MM/DD/YY)
10. INJURY DATE 11. TIME AM
PM
12. Have you missed work due to your injury? If so, what dates were you off?
From: To:
13. SEX 14A. MARITAL STATUS 14B. NUMBER OF DEPENDENTS
EMPLOYER'S TELEPHONE NUMBER
(360) 716-5067
EMPLOYER'S SERVICE REP PHONE
1-877-777-8039
15. Describe in detail how your injury or exposure occurred:
Attending Health Care Provider- START HERE
22.Date patient first seen by you for this injury/condition:
16. MEDICAL RELEASE AUTHORIZATION:
I HEREBY AUTHORIZE MY HEALTH CARE PROVIDER, HOSPITAL, AGENCY OR ORGANIZATION TO
DISCLOSE TO MY EMPLOYER OR MY EMPLOYER'S REPRESENTATIVE ANY RELEVANT MEDICAL
RECORDS OR OTHERINFORMATION REGARDING TREATMENT PREVIOUSLY FURNISHED TO ME.
Worker's Signature Date: a. ICD DX CODES
b. Diagnosis - specify Right/Left
23. Are there objective findings to support this diagnosis
No
Yes, Specify
17. NOTICE: Making any knowingly false or fraudulent statement or withholding information is unlawful. Worker's Signature: Date:18. a. Has the worker ever been treated for the same or similar condition?
Select one. If YES, describe briefly or attach report.
No
Yes
_________________________________________________________
b. Is there any pre-existing impairment of the injured area?Select one. If YES, describe briefly or attach report.
No
Yes
_________________________________________________________
c. Are there any conditions that will prevent or retard recovery?Select one. If YES, describe briefly or attach report.
No
Yes
_________________________________________________________
d. Was the diagnosed condition caused by this injury or exposure on a more probable than not basis?No
Yes
24. Referred for Diagnostic Studies
No
Yes, Specify
19. a. Have you released this worker to return to regular work?
No
Yes
effective date of return to work b. Have you released this worker to return to light duty?No
Yes
effective date of return to work c. What restrictions are placed on light duty return to work?Lifting __________________________________________
Bending_________________________________________
Standing________________________________________
Sitting__________________________________________
Other___________________________________________
d. If not released, how many days off work due to the work injury? 25. Treatment Recommendations:
20.Licensed Healthcare Provider must sign before report is accepted
Signature: Date: Phone:
DO
NOT
SEND
THIS
FORM
TO
LABOR &
INDUSTRIES
26. Referred Healthcare Provider (Patient Referred for Follow-Up)
Address:
Phone:
21. Attending Healthcare Provider Name:
Address:
City: State: ZIP:
G
ener
al
Inf
o
Worker’s Name:
Visit Date:
Claim Number:
Healthcare Provider’s Name (printed):
Date of Injury:
Diagnosis:
Requ
ired
: R
ele
ase
d f
or
w
or
k?
C
hec
k
a
t
le
a
s
t
o
ne
Worker is
released
to the job of injury without restrictions on (date): ____/____/____
Skip to “Plans” section below.
Worker
may perform modified duty
, if available, from (date):
______/_______/_______ to _______/_______/_______
______/_______/_______ to _______/_______/_______
working
Please estimate capacities below and provide key objective findings at right.
Required:
Key Objective Finding(s)
Worker
not released to any work
from (date):
____/____/____ to ____/____/____
Prognosis poor for return to work
at the job of injury at any date
May need assistance returning to work
Capacities apply 24/7, please estimate capacities below and provide key objective findings at right.
Requ
ired
: E
stim
ate
w
hat t
he wo
rke
r c
an d
o
U
nl
e
s
s
re
le
a
s
e
d
t
o
J
O
I
)
1-
11
-
Worker can: (Related to work
injury.) Blank space = Not restricted Never
Seldom 1-10% 0-1 hour Occasional 11-33% 1-3 hours Frequent 34-66% 3-6 hours Constant 67-100% Not restricted
