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Workers' Compensation Forms and Brochures
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Welcome to the Workers' Compensation Forms & Brochures Page. This is where County employees can find forms and brochures for all Workers' Compensation Programs. |
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- Reading PDF forms requires Acrobat Reader. To download Acrobat Reader, click on the image below.
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FORMS and BROCHURES
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This is the employer's report of industrial injury. The employing department and injured employee completes this form and sends to CEO-Risk Management Division's Disability Management Unit as soon as possible after the employing department is notified of the injury (faxed to 525-5779 and original sent via Inter-department Mail).
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The employing department must provide this form as soon as they have knowledge that an employee has an injury or illness that requires medical attention and or the employee misses a day or more from work due to a work related injury or illness. The injured employee must complete lines 1 - 8 of the report and then submit the form to the CEO-Risk Management Division's Disability Management Unit who will complete lines 9 - 18. The County and it's Third Party Administrator will have up to 90 days to investigate a claim to determine compensability.
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This brochure is provided to all new employees and again to all employees at the time they file a workers' compensation claim. Link to the MPN website: www.hmcmpn.com Employer Code STANMPN
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Authorized Occupational Medical Providers.
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This form allows the County's Third Party Administrator to obtain medical information about the injury from treating physicians. The injured employee prepares the form when the injury or illness is reported to the employing department and submits the form directly to the CEO-Risk Management Division's Disability Management Unit.
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This form allows Kaiser to transmit medical records that pertain to the claimed work related injury or illness directly to the County's CEO-Risk Management Division's Disability Management Unit and to the County's Third Party Administrator. The injured employee prepares the form when the injury or illness is reported to the employing department and submits the form directly to the County's CEO-Risk Management Division's Disability Management Unit.
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Authorization for treatment by a primary care physician. The employing department prepares the form and gives it to the injured employee when notified of the injury. A copy of the completed form is sent by the department to the CEO-Risk Management Division's Disability Management Unit (faxed to 525-5779 and original sent via Inter-department Mail).
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This is for the physician's use in identifying any temporary work restrictions that may be appropriate for an injured or ill employee. This data will be used by the department to determine if they can safely accommodate any temporary work restrictions. If the medical facility has a similar reporting form available they may submit their own form in lieu of using the County's form. This form or the medical clinic's equivalent form is sent to the CEO-Risk Management Division's Disability Management Unit after each medical appointment visit.
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If the employee is taken off work due to an On the Job Injury/Illness for 3 or more days, the employee shall complete the Leave of Absence Request Form and submit to the County's CEO-Risk Management Division's Disability Management Unit. For further information see the Family & Medical Leave Act policy and procedure on the Medical Leaves Policy & Procedures webpage.
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When the employee is provided with work restrictions the department
should complete a Medical Work Restriction Agreement, both the employee
and his supervisor should sign the agreement and submit to the County's
CEO-Risk Management Division's Disability Management Unit.
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The supervisor of the injured or ill employee should complete this report within 48 hours of the first notification of injury or illness. The report is intended to afford the supervisor an opportunity to evaluate the cause of the injury and what corrective action can be taken to prevent a recurrence. A copy of this report is sent to the CEO-Risk Management Division's Disability Management Unit along with the Employee On the Job Injury/Illness Report and the original is sent to the Safety Unit.
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This form is optional but should be completed and submitted along with the Employee On the Job Injury/Illness Report if there were witnesses to the claimed event.
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Employees may designate their primary care physician with their health insurance plan prior to incurring an industrial injury or illness. Conditions governing the selection of the physician are described on the form. The employee completes the form and gives it to the employing department. The employing department then submits the form to the County's CEO-Risk Management Division's Disability Management Unit.
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Required Poster.
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Required Pamphlet.
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