Workers’ Compensation
All work-related injuries or illnesses must be reported.
If the injury is an emergency, arrange for appropriate medical treatment. The
employee has the right to select his or her own network physician; so please refer
the employee to a Network Provider. If employee is incoherent, the supervisor or
administrative staff may select an emergency facility. If possible, send a
responsible employee to accompany the injured employee.
Please ensure the following forms are completed:
EMPLOYEE’S FIRST REPORT OF INJURY OR ILLNESS
SUPERVISOR’S DETAILED DESCRIPTION OF INJURY/ILLNESS
WORKERS COMPENSATION NETWORK ACKNOWLEDGEMENT
PROVIDER NOTIFICATION OF ON-THE-JOB INJURY
WORKERS' COMPENSATION (WCI 23) REQUEST FOR PAID LEAVE
Fax forms to (210) 458-7450 (Workers' Compensation Insurance Office in Environmental Health Safety
and Risk Management) within 24 hours from the time of the injury. Once the form has been faxed,
send the original form through campus mail to EHSRM. These forms are required whether or not there is
lost time from work.
Do not delay medical treatment to complete Workers’ Compensation paperwork. Take all reasonable
steps necessary to guard, provide warnings, or correct condition which caused the injury.
If you need assistance to accomplish the correction, call EHSRM at (210) 458-5250.
THE UNIVERSITY OF TEXAS SAN ANTONIO / EMPLOYEE’S FIRST REPORT OF INJURY STATEMENT
[Please have employee complete.]
*PLEASE PRINT*
Name: ________________________________________________________________ Social Security Number_________________________ � Male � Female
Address:
Street______________________________________________City____________________________County_____________________State___________Zip___________ Street or Box Apt.
Home Phone: (______) ___________________ Campus Phone: (______) ___________________ EID: ____________________ Date of birth:________________ Marital Status: Married Spouse’s name: _____________________________________________________________________
Widowed Single Separated Divorced Number of Dependents: __________
Date of Injury: ________________________ Time of Injury: ______________ AM PM Job Title: ____________________________________________
Injury Location: ______________________________________________________________________________________________________________________ Building Area Floor Room No.
Type of injury: □ Burn □ Cut/Laceration □ Bruise □ Strain □ Needle stick □ Repetitive Motion □ Exposure □ Bite □ Other ____________________________________________ □ None (Incident Only)
Were you advised of safety policies and procedures required for this job? □ Yes □ No □ Not Applicable
If no, please explain: __________________________________________________________________________________________________________________ Did you notify your supervisor? □ Yes □ No If YES, date and time of notification: ___________________ _________________ Department: ________________________ Supervisor: ____________________________________________ Supervisor Phone: (_______) __________________
**I have been offered medical attention but do not wish to receive any at this time. ** (Initial here) ___________
If requesting medical treatment, who did YOU select as your treating doctor/facility? ______________________________________ Tel. No.___________________
Please fill out a “Notification of Injury” form and take it with you to the physician. Contact UT System Claims Analyst at 1-888-396-6844, ASAP.
Please designate the injured body part(s) as reported above.
INFORMATION RELEASE
The above statement is true and accurate to the best of my knowledge. I hereby authorize any licensed physician, medical practitioner, hospital, clinic or other medical or medically related facility, insurance company or other organization, institution or person that has any records or knowledge of me, or my health, to furnish to the U.T. System, UTSA Workers Compensation Office or its representative any and all information relevant to the injury or illness which I am reporting, including: medical history, consultation reports, hospital records, etc. A photostatic copy of this authorization shall be considered as effective and valid as the original.
Signature of Employee: _______________________________________________________________________ Date: ______________________________ 02/17/14 VERS.3.1
Explain how and why this injury occurred (Provide as much detail as possible)
Item or equipment involved in accident:
□ Ankle □ Shoulder
□ Head □ Upper Back
□ Foot □ Upper Arm
□ Face □ Lower Back
□ Upper Leg □ Lower Arm
□ Eye(s) □ Buttocks
□ Lower Leg □ Elbow
□ Nose □ Abdomen (including groin)
□ Hip □ Wrist
□ Mouth □ Pelvis
□ Knee □ Hand
□ Neck □ Chest
□ Toe(s) □ Fingers
FORWARD COMPLETED FORM TO WCI OFFICE, ENVIRONMENTAL HEALTH, SAFETY & RISK MANAGEMENT, PH # 458-8178, FAX 458-7450
Who witnessed the injury/illness/accident? Name(s) address and telephone number(s). Social Security Number
(1) with few exceptions, the individual is entitled on request to be informed about the information that the state governmental body collects about the individual; (2) under Sections 552.021 and 552.023 of the Government Code, the individual is entitled to receive and review the information; and
THE UNIVERSITY OF TEXAS SAN ANTONIO / EMPLOYEE’S FIRST REPORT OF INJURY STATEMENT SUPERVISOR’S DETAILED DESCRIPTION OF INJURY / ILLNESS AND ACCIDENT SCENE
[Supervisor should complete.]
*PLEASE PRINT*
Injured Employee: __________________________________________ Injured Employee EID#_________________________________________ President’s Office (includes Audit, Compliance and Risk Services; Equal Opportunity Services; and Office of Legal Affairs)
President’s Office ACRS EOS OLA
Vice Presidents
Academic Affairs External Relations Business Affairs
Community Services
____________________________________ Research Student Affairs Associate/Assistant VP area or College:
Facilities
Administration Downtown/HemisFair Park Campuses Engineering and Project Management Main Campus Housekeeping Main Campus Operations & Maintenance
Date of Injury: ________________________ Time of Injury: ______________ AM PM Job Title: ___________________________________________ Injury Location: ______________________________________________________________________________________________________________________ Building Area Floor Room No.
4. Was employee doing his/her regular job? □ Yes □ No 5. Was there physical evidence of injury to the body part in question? □ Yes □ No
If yes, please describe (swelling, bruising, laceration etc.) _______________________________________
6. Does the employee speak English? □ Yes □ No If no, what language? __________________________________ 7. Injured employee’s date of hire: _____________________________ Occupation of Injured Worker: ____________________________ Length of service in current position: _________________________ Length of service in Occupation: __________________________
8. Was the employee wearing personal protection equipment, which would have prevented the injury or occupational disease? □ Yes □ No □ Not Applicable 9. Was the employee advised of safety policies and procedures to prevent further occurrences? □ Yes □ No
10. Was medical treatment given to the employee? □ Yes □ No 11. Was the employee given the opportunity to choose their treating physician? □ Yes □ No
12. If taken for medical treatment, name of facility: _________________________________________________________________________________ 13. Did a department representative accompany the employee to the medical facility? □ Yes □ No
If yes, please provide the representative’s name: ___________________________________________________________________________ 14. Has the employee lost time from work due to this injury? □ Yes □ No If yes, date lost time began: _________________________ 14a. Has the employee returned to work? □ Yes □ No If yes, date returned to work: _________________________ The above statement is true and accurate to the best of my knowledge.
Supervisor Name: ____________________________________________ Supervisor Signature: ____________________________________________ Date: ______________________________________________________ Campus Ph. #: _________________________________________________
FORWARD COMPLETED FORM TO WCI OFFICE, ENVIRONMENTAL HEALTH, SAFETY & RISK MANAGEMENT, PH # 458-8178, FAX 458-7450
REV 4/15
2. Based on your inquires, explain how and why this injury occurred:
Cause of injury (fall, tool, machine, ground, wet floor etc.) _____________________________________________________________________________ 1. Describe the type of work area where the accident occurred (stairs, dock, office, hallway, street, etc.)
Please explain any unusual conditions that were present at the time of the injury.
3. Who witnessed the injury/illness/accident? Name(s) address and telephone number(s).
Not Applicable
REV 4/13
Workers’ Compensation Network Acknowledgement
I have received information (Employee Welcome Letter, Notice of Network Requirements and Employee
Handbook Material) which informs me how to get health care under workers’ compensation insurance.
If I am hurt on the job and live in the service area described in this information, I understand that:
1. I must choose a treating doctor from the list of physicians in the IMO Med-Select Network
®. Or, I may ask my
HMO primary care physician to agree to serve as my treating doctor by completing the Selection of HMO
Primary Care Physician as Workers’ Compensation Treating Doctor Form # IMO MSN-5.
2. I must go to my network treating doctor for all health care for my injury. If I need a specialist, my treating
doctor will refer me. If I need emergency care, I may go anywhere.
3. The insurance carrier will pay the treating doctor and other network providers.
4. I may have to pay the bill if I get health care from someone other than a network doctor without Network
approval.
5. If I receive the Notice of Network Requirements and refuse to sign the Acknowledgement form, I am still
required to use the network.
Please fill out the following information before signing and submitting this completed acknowledgement form:
Name of Carrier: The University of Texas System
Employee ID #: __________________________ Name of Network: IMO Med-Select Network
®Hire Date: ______________________________ Department: __________________________
Home Address:
________________________________________________________________
Street Address – No P.O. Box or Work Address
_________________________________________________________________
City State Zip Code
County
_______________________________________________
_____________________
Employee Signature Date
_______________________________________________
_____________________
Printed Name
Employee Phone Number
FORWARD COMPLETED FORM TO WCI OFFICE, ENVIRONMENTAL HEALTH, SAFETY & RISK MANAGEMENT, PH # 458-8178, FAX 458-7450
THE UNIVERSITY OF TEXAS AT SAN ANTONIO WORKERS’ COMPENSATION INSURANCE
REQUEST FOR PAID LEAVE
PLEASE COMPLETE AND FORWARD PROMPTLY
___________________________ ___________________________ _______________________
Name Claim Number Date of Injury
IF YOU SUSTAIN AN ON-THE-JOB INJURY COVERED BY WORKERS’ COMPENSATION INSURANCE, THE UNIVERSITY OF TEXAS SYSTEM WILL PAY REASONABLE AND NECESSARY
MEDICAL BILLS RESULTING FROM THE INJURY IN ACCORDANCE WITH THE TEXAS WORKERS’ COMPENSATION ACT AND WILL ALLOW YOU TO REMAIN ON THE PAYROLL
USING ALL PAID LEAVE AVAILABLE TO YOU.
IF YOU ARE STILL UNABLE TO WORK AFTER USING PAID LEAVE AND ARE REMOVED FROM THE PAYROLL, WORKERS’ COMPENSATION TEMPORARY INCOME BENEFITS (TIBS) WILL
BEGIN AS PRESCRIBED BY LAW.
IF YOU CHOOSE TO USE PAID LEAVE, YOU MUST FIRST EXHAUST SICK LEAVE. ONCE YOUR SICK LEAVE HAS BEEN EXHAUSTED, YOU MAY THEN CHOOSE TO USE ONE OR MORE WEEKS OF OTHER PAID LEAVE IN LIEU OF RECEIVING TIBS. PRIOR TO MAKING AN ELECTION CONCERNING THE USE OF OTHER PAID LEAVE, PLEASE BE ADVISED
THAT ALTHOUGH THERE IS A SEVEN-DAY WAITING PERIOD WHERE TIBS ARE NOT PAYABLE, SHOULD DISABILITY EXTEND TO THE 14TH DAY AFTER THE FIRST DAY DISABILITY, THE CARRIER WILL THEN ISSUE A TIBS PAYMENT FOR THE WAITING PERIOD.
TIBS ARE NEVER PAYABLE AS LONG AS YOU ARE USING PAID LEAVE.
_____ I wish to use sick leave to remain on the payroll until such leave is exhausted. I currently
have hours of sick leave available to remain in the payroll from _______________ to ________________. _____ I do not wish to use sick leave. Please place me on leave without pay for all time lost.
I understand that temporary income benefits (TIBS) will begin following the statutory seven-day waiting period, provided I have not been released to return to work. _____ Sick leave has been exhausted. I wish to use other paid leave to remain on the
payroll from _______________ to _______________.
_____ No leave is available or all accrued leave has been exhausted. Employee will be placed on leave without pay as of _______________.
____________________________________________ ____________________________________________
Employee Date
____________________________________________ ____________________________________________ Supervisor Date
____________________________________________ ____________________________________________
Employer Official Date
Provider notification of an on-the-job injury
This form shall act as your notification for your workers’ compensation insurance coverage. This form is to be presented to the physician’s office, hospital emergency room, pharmacy or other authorized provider that is treating you for your work related injury. If you have any questions regarding your workers compensation coverage, please contact the UTSA Workers Compensation Office at 210-458-8178 Employee Name: Date of Birth: Date of Injury: SSN: Department: Provider:
PLEASE COPY THIS FORM AND RETURN TO EMPLOYEE
This employee has claimed a work related injury and may be covered by Workers’ Compensation Insurance through the University of Texas System. The University of Texas at San Antonio is a self-funded employer. Claims are processed through the University of Texas System in Austin. Pre-Authorization:
For pre-authorization, please call 214.217.5939 or toll-free at 888.466.6381 or fax to 214.217.5937 or 877.946.6638.
THIS FORM DOES NOT CERTIFY COMPENSABILITY OR GUARANTEE PAYMENT
Please submit bills, medical reports, or questions to: The University of Texas System
Office of Risk Management Workers’ Compensation Insurance Office
P.O. Box 802082 Dallas, Texas 75380
1-888-802-0692 FAX (972) 386-7918
Pharmacy:
The University of Texas System has partnered with Modern Medical to make filling prescriptions easy.
Please use this form as a temporary prescription card. Please process prescriptions for the worker’s compensation injury only. This form is only valid if signed and dated by UTSA employer representative.
For questions or rejections, please call (800) 547-3330. Please DO NOT send employee home or have employee pay for medication(s) before calling Modern Medical for assistance.
Modern Medical Group #:
B31028
Processor:
Modern Medical
Bin#:610011
Pcn#:
IRX
Modern Medical Help Desk:
(800) 547-3330
Day supply is limited to7
days for a new injuryInjured Employee:
PLEASE KEEP A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS
Please feel free to contact the UTSA Workers Compensation Insurance office at (210) 458-8178 to assist you in locating a Workers Compensation Treating Medical Provider.
Please contact the UT System/CCMSI Claim Adjuster at (888) 802-0692 as soon as possible, following your injury.
A permanent Modern Medical prescription card specific to your injury will be forwarded directly to you within the next 3 to 5 business days.
Please take this form and your prescription(s) to a pharmacy near you. Modern Medical has a network of pharmacies nationwide. If you need assistance in locating a network pharmacy near you, please call Modern Medical toll free at (800) 547-3330 or ”Find a Pharmacy” search tool at
www.modernmedical.com.
If you are denied medication(s) at the pharmacy, please call (800) 547-3330.
MODIFIED DUTY MAY BE AVAILABLE, PLEASE CONTACT THE UTSA WCI OFFICE AT 210-458-8178
