Orange Unified School District Injury and Illness Prevention ......Injury and Illness Prevention S.Solis Orange Unified School District Injury and Illness Prevention Program (IIPP)

Injury and Illness Prevention S.Solis

Orange Unified School District

Injury and Illness Prevention Program

(IIPP) CCR Title 8, § 3203

Risk Management 1401 N. Handy St. Orange, CA 92867

(714) 628-5390


Preface

Orange Unified School District (OUSD) is committed to providing a safe and healthful environment for all staff, students, and parents. In pursuit of this endeavor, the OUSD Injury Illness Prevention Program (IIPP) has been established to provide a framework for OUSD to ensure a safe and healthy work environment for all of its employees.

The goal of the program is to eliminate occupational injuries and illnesses. This program has been developed and implemented as required under the California Code of Regulations (CCR), Title 8, Chapter 4, Subchapter 7, and Section 3203.

The purpose of this document is to provide information necessary to communicate the elements of the IIPP.

The IIPP guidelines and procedures described in this document are designed for use by OUSD administration and staff. Administration and employees are encouraged to read this document and are required to follow the guidelines and procedures set forth in this document, unless otherwise stipulated.

This document provides the following information:

Section 1, Policy StatementDescribes the commitment of OUSD to this IIPP program and the reasonsfor developing this IIPP.

Section 2, ResponsibilityDefines the IIPP-related responsibilities of employees and specificOUSD management personnel.

Section 3, ComplianceDescribes OUSD’s commitment to compliance and actions to be taken if employeesdo not comply with the IIPP program.

Section 4, CommunicationDiscusses the means of communicating IIPP requirements between managementand staff.

Section 5, Accident Reporting and Investigation ProceduresExplains how employees should report workplace injuries and the requirementsfor reporting certain injuries to Cal/OSHA. Explains how Supervisors shouldperform employee accident investigations and identifies the OUSD policy forenabling investigations by external organizations.

Section 6, Hazard CorrectionDescribes the responsibilities and process related to correcting hazards in theworkplace.

Purpose of This Document

Intended Audience

What’s Inside this Document


Section 7, Training and InstructionDiscusses the methods of training employees on safety issues.

Section 8, Record-KeepingIdentifies the requirements for storing safety related documentation.


Table of Contents

Policy Statement ..................................................................................................... 1

Responsibility ..................................................................................................... 2-4

Overview Director of Risk Management Management/Principals Responsibilities Supervisor Responsibilities Maintenance and Operations Responsibilities Employee Responsibilities Employee Rights

Compliance ............................................................................................................. 5

Overview District Commitment Employee Compliance Disciplinary Action

Communication ................................................................................................... 6-7

Overview General Information New Employee Orientation Training Program Posted/Distributed Information Review of Injury & Illness Prevention Program

Hazard Assessment ................................................................................................. 8

Overview Hazard Reporting System Workplace Hazard Detection

Accident Reporting and Investigation Procedures ............................................. 9-11

Overview Injured Employee Procedure Reports to Cal-OSHA

Investigation

Overview Supervisor’s Accident Investigation Outside Agency Investigation

Hazard Communication and Correction ................................................................ 12-13

Overview Hazard Correction Responsibilities

Directors and Principals Supervisors Employees Maintenance & Operations Department

Controlling Access to Areas Containing Hazards Hazard Correction Follow-Up


Training and Instruction ................................................................................. 14-15

Overview New Employee Orientation Initial Job Instruction Pre-Job Safety Instructions for Non-Routine Hazardous Jobs Safety Talks

Planned Safety Talks Correctional Safety Talks

Record-Keeping ..................................................................................................... 16

Overview Safety Evaluation Documentation Employee Injury Reports and Supervisor Accident Investigation Reports Environmental/Employee Medical Monitoring

Appendix A........ ..................................................................................................... A-1 List of Employee Mandatory Trainings

Appendix B.............................................................................................................B-1 Sample Workers Compensation Packet

Appendix C.............................................................................................................C-1 Sample Posters

Injury and Illness Prevention Program 1

Policy Statement

The Orange Unified School District (OUSD) is committed to providing a safe and healthful workplace for all of its employees. The personal safety of each school district employee while in performance of his or her work activity is of primary importance.

This Injury & Illness Prevention Program (IIPP) has been developed to ensure that the District takes all measures to effectively reduce the number of occupational injuries and illnesses. The success of this program is to be achieved through the continuous mutual cooperation and support of management and employees.

OUSD is also committed to ensuring that a safe and healthful workplace exists for outside contractors and other workers that may be working at District sites. OUSD is also committed to ensuring that all health and safety regulations are adhered to by all affected employees.


1 Responsibility

Section

This section of the OUSD IIPP defines the responsibilities of the Director of Risk Management, OUSD Management/Principals, Supervisors, Maintenance & Operations, and employees. Employee rights are also listed.

The Director of Risk Management will serve as the IIPP Coordinator for OUSD. The IIPP Coordinator is responsible for implementing and maintaining the following aspects of the safety program:

Coordinating all risk control activities.

Maintaining, evaluating, and revising the IIPP and conducting investigation ofdisabling injuries.

Providing advice and guidance to District Management/Principals, and Supervisors.

Communicating safety objectives.

Developing and/or assisting in the development of employee training programs.

Reviewing all accident reports and investigations.

Ensuring the District is adhering to federal, state, and local safety codes.

Serving as liaison between management and outside safety agencies.

OUSD Management/Principals are responsible, where appropriate, for specific elements of the IIPP as follows:

Managing the injury prevention efforts in their area of responsibility.

Providing the necessary means of ensuring a safe and healthy work environmentfor their staff.

Providing supervisors and employees with safety training and job instruction.

Overview

Director of Risk Management

OUSD Management/Principals Responsibilities

Responsibility

Managing a planned safety meeting or safety talk program.

Managing safety discipline.

Ensuring compliance with federal, state, and local safety codes. Cal/OSHA safety regulations can be found in CCR Title 8. These regulations can be accessed via the Internet at: https://www.dir.ca.gov/title8/index/t8index.asp

Participating in the investigation of disabling injuries.

Supervisors have an integral role within the IIPP. Supervisors are in constant and direct contact with their employees and can greatly influence safety attitudes and practices. It is essential that Supervisors set the example for employees in regards to safety responsibilities. There are several specific responsibilities for Supervisors, as follows:

Taking any reasonable action necessary to prevent injuries where an immediate

danger exists.

Taking responsibility for safety of all employees under their supervision and for any employee not under their supervision but in the supervisor’s work area.

Providing and maintaining a clean and hazard-free work area.

Providing safety orientation and job instruction of supervised employees.

Planning, conducting, and documenting safety evaluations in assigned areas of responsibility.

Conducting planned safety meetings with employees.

Conducting safety observations of employee safe work practices.

Developing and maintaining cooperative safety attitudes in employees through the application of approved methods or preventive and corrective discipline

The OUSD Maintenance & Operations Department has a critical role in maintaining all sites and facilities in proper and safe condition. The IIPP-related responsibilities of the Maintenance & Operations Department are as follows:

Responding immediately to maintenance work requests concerning safety related

issues. These maintenance requests must be given the highest priority.

Procedures in accordance with Cal/OSHA lock out/tag out regulations will be strictly adhered to for locking, blocking, and tagging out unsafe equipment, electrical circuitry, and equipment with moving parts. Lock out/tag out procedures will be used if equipment is in need of repair or is no longer in use.

All equipment shall be used in a safe manner for which the equipment is intended and in accordance with manufacturers’ instructions and recommended rules for safe operation.


Supervisor Responsibilities

Maintenance & Operations Responsibilities

http://www.dir.ca.gov/title8/index/t8index.asp

http://www.dir.ca.gov/title8/index/t8index.asp

Responsibility

Contracting with outside vendors as necessary to complete repairs that the

Maintenance & Operations Department is not trained, equipped, or qualified to conduct.

Posting required safety related signs as requested by District Management and Site Administrators.

Employees are charged with adhering to the IIPP as directed by management. Employees are responsible for:

Adhering to all safety rules and operating procedures established by the District.

Wearing appropriate personal protective equipment (PPE) as required and provided by the District.

Inspecting and maintaining equipment for proper and safe operation.

Reporting all injuries immediately.

Encouraging other workers to work in a safe manner.

Reporting all observed unsafe acts and conditions to their Supervisor.

Reporting to work in an acceptable condition and not under the influence of alcohol or drugs.

Employees have several rights with respect to occupational safety. Employees have the right to:

Safe and healthful working conditions.

Receive training in general safe work practices and specific training with regard to hazards unique to any job assignment.

Refuse work that would violate a health and safety standard or order where such violation would pose a real and apparent hazard to their safety or health.


Employee Responsibilities

Employee Rights


2 Compliance

Section

This section of the OUSD IIPP describes the District’s commitment to compliance, expectations regarding employee compliance, and action to be taken if employees do not comply with their responsibilities under the IIPP program.

OUSD is committed to the following:

Providing all employees a safe and healthy work environment.

Providing necessary Personal Protective equipment (PPE) and safety training to employees.

Maintaining an open door policy allowing all employees to communicate any safety concerns.

Adhering to all federal, state, and local safety regulations.

Providing full cooperation with any outside safety agency during the course of any inspection or audit.

Occupational safety and health regulations and workplace practices are designed to reduce or eliminate employee occupational injuries and illnesses. Employee compliance with all rules and regulations is essential to maintaining a safe and healthy workplace. Employees that violate any safety policy, procedures, rules, and/or regulations may be subject to disciplinary action.

OUSD utilizes progressive disciplinary action as the preferred method of discipline for employees who violate District policies, rules, and procedures. The objective of progressive discipline is to correct unacceptable behavior or performance of an employee. In the event an employee violates any safety rules or requires any counseling as a result of unsafe work practices, the District will use progressive disciplinary procedures. In most instances these steps apply. However, if the performance or behavior has been sufficiently serious or frequent, it may be appropriate to modify the disciplinary procedures.

Please refer to the District’s disciplinary procedures, bargaining unit contracts or with the Human Resources Department for further information regarding discipline.

Overview

District Commitment

Employee Compliance

Disciplinary Action


3 Communication

Section

This section of the OUSD IIPP discusses the requirements for communicating IIPP compliance between management and staff. Information is provided in appendices regarding communication mechanisms such as employee training, program reviews, and printed/posted literature.

OUSD recognizes that open, two-way communication between management and staff on health and safety issues is essential to an injury-free, productive workplace.

Managers, Supervisors, Principals, Directors, and Site Administrators are

responsible for communicating with all employees about occupational safety and health issues in a manner or form readily understandable by all employees.

Employees are encouraged to inform their Managers and Supervisors about workplace hazards without fear of reprisal.

The system of communication regarding safety and health at OUSD consists of several facets of delivery designed to facilitate a continuous flow of safety and health information between management and staff. Such delivery methods include New Employee Orientation training, ongoing safety training, and posted or distributed information.

All new OUSD employees are required to take a new-hire orientation/training. Safety information communicated to each employee will include, but not be limited to, fire procedures, hazard communication, first aid procedures, blood borne pathogens, back injury prevention, PPE, and injury reporting, where applicable.

Documentation of all new employee training will be maintained in the Risk Management Office via the use of Keenan SafeSchools.

Overview

General Information

New Employee Orientation

Communication

OUSD is committed to providing all necessary safety training to its employees. Safety training programs are necessary for the District to communicate to employees the hazards associated with their positions and safe work practices necessary to mitigate those hazards.

Training will be communicated through dialog between trainer and trainee, on-line courses, safety videos, safety literature, hands-on example, on-the-job training, seminars, and workshops. Communication during training sessions should be two-way to ensure that employees understand their training and are afforded the opportunity to ask questions to clarify any information they may not understand initially.

The Director/Supervisor/Principal will review the effectiveness of specific training programs and recommendations will be communicated to the necessary personnel or agencies conducting the training.

OUSD is committed to providing its employees with accurate and timely safety information. Safety literature, policies/procedures, concerns, and other safety information will be posted in an area accessible to all employees and posted on the District’s web site.

Warning signs and other indicators of a hazardous condition will also be posted at the work site where hazards exist in accordance with applicable laws or District policies.

This IIPP is to be used as a reference source for safety information pertaining to OUSD. All employees are entitled to review the contents of this IIPP. Each site should have a copy of the program, which must be kept at a location readily accessible to all employees.

All new employees will be informed of the program during orientation.

All employees will be notified of any revisions to the program as the revisions are made.


Training Programs

Posted/Distributed Information

Review of Injury & Illness Prevention Program


4 Hazard Assessment

Section

This section of the OUSD IIPP discusses the process for assessing and analyzing hazards to which OUSD employees may be exposed.

It is the responsibility of all employees to report unsafe work conditions and practices to their appropriate Supervisor or Site Administrator. Unsafe conditions can be submitted anonymously by calling the Risk Management Department at (714) 628-5390.

The District is committed to conducting complete and thorough investigation of all reports of hazardous conditions. If conditions are determined to be hazardous, appropriate measures will be taken by the District to correct those conditions.

The detection of hazards in the workplace is essential in ensuring a safe work environment. Undetected and uncorrected safety hazards may cause accidents resulting in serious injury to employees.

There are two major sources of unsafe conditions:

Normal wear and tear of equipment

Normal wear and tear is the constant process where equipment and areas of facilities deteriorate. Evaluations of equipment and areas can detect hazardous conditions before they cause injury.

Employee actions Employee actions can contribute to unsafe conditions in several ways, such as mis- using or abusing equipment, which can be dangerous. Employees may also leave their work area untidy, which creates a dangerous environment.

Overview

Hazard Reporting System

Workplace Hazard Detection


5 Section

Accident Reporting Procedures

This section of the OUSD IIPP explains how employees should report and follow-up on workplace injuries and the requirements for reporting serious and fatal injuries to Cal/OSHA.

The following instructions pertain to employees injured in the workplace.

Immediately report all injuries, mishaps or near misses to your Supervisor. Dial 911 if injury requires immediate attention.

Complete the following Worker’s Compensation forms

Employee Statement of Occupational Injury or Illness

Authorization for Release of Patient Health Information California Workers’ Compensation Claim Form (DWC 1)

Receive medical attention at a District approved medical facility.

If you are authorized to return to work, provide a Certificate for Return to Work or Further Treatment, provided by the physician, to the Risk Management Office and to your Supervisor. If there are any work restrictions, review modified duties with the Risk Management Office and your Supervisor.

If you are unable to return to work, notify your Supervisor and provide a copy of an off-work statement from the Physician to the Risk Management Office and to your Supervisor.

Serious and fatal injuries are to be immediately reported to Cal-OSHA by the Director of Risk Management or designee. Immediately means as soon as practically possible but not longer than 8 hours after the District knows.

Serious injuries warranting Cal/OSHA notification include injuries that occur in a place of employment or in connection with any employment which requires inpatient hospitalization for a period in excess of 24 hours for other than medical observation or in which an employee suffers a loss of any member of the body or suffers any serious degree of permanent disfigurement, but does not include any injury or illness or death caused by the commission of a Penal Code violation, except the violation of Section 385 of the Penal Code (high voltage accident in excess of 750 volts), or an accident on a public street or highway.

If the District can demonstrate that exigent circumstances exist, the time frame for the report may be made no longer than eight (8) hours after the incident.

Overview

Injured Employee Procedure

Reports to Cal-OSHA

9


Accident Reporting Procedures

When making such report, whether by telephone or fax, the Director of Risk Management or designee shall include the following information, if available:

Time and date of accident.

School’s name, address, and telephone number.

Name and job title of person reporting the accident.

Address of site of accident or event.

Name of person to contact at site of accident.

Name and address of injured employee(s).

Nature of injury.

Location where injured employee(s) was (were) moved to.

List and identity of other law enforcement agencies present at the site of accident.

Description of accident and whether the accident scene or instrumentality has been altered.

Accident Investigation

This section of the OUSD IIPP explains how Supervisors should perform an employee accident investigation and identifies the OUSD policy for enabling investigations by organizations outside the District.

Understanding the root cause of an accident will allow management to apply measures to prevent similar accidents from recurring. Determining the root cause may be a difficult or arduous task. A diligent investigation will allow management to understand the root cause.

Procedures for investigating employee injuries include:

Visiting the accident scene as soon as possible. This allows the Supervisor to see

the scene of the accident before any alterations to the scene can be made. It also allows the Supervisor to be visible and available to employees in the area.

Interviewing injured workers and witnesses.

Examining the workplace for factors associated with the accident. It is essential to inspect the scene of the accident to determine if any hazards are present that may cause future accidents.

Determining the cause of the accident.

Taking corrective action to prevent the accident from reoccurring. Initiating appropriate work orders when the incident reveals a maintenance or repair issue that could mitigate any future incidents of the same nature. Immediate and complete corrective action is essential.

Documenting the findings and corrective actions taken by completing Supervisor’s Accident Investigation Report.

Overview

Supervisor’s Accident Investigation

10


Accident Investigation Procedures

Serious injuries and fatalities may also be investigated by agencies outside of the District. Insurance agencies as well as Cal/OSHA, Fire Departments, Law Enforcement Agencies, and the District Attorney may desire to investigate serious accidents and fatalities.

The District will cooperate with and assist outside agencies during the course of these investigations.

Outside Agency Investigation

11


6Section

Hazard Communication and Correction

This section of the OUSD IIPP describes the responsibilities and process related to correcting hazards in the workplace.

The correction of any identified hazards should be conducted immediately upon detection. Personnel at all levels of employment have responsibilities in hazard correction. All personnel should have an understanding of their role in hazard correction to effectively eliminate identified hazards.

A work order needs to be generated to the Maintenance and Operations Department regarding safety hazards.

Directors and Principals Upon the identification of an unsafe/unhealthy work condition or practice, the Directors and Principals shall:

Initiate the appropriate corrective action by way of a work order or communicationwith Maintenance and Operations or Risk Management.

Handle conditions involving a serious concealed danger personally until appropriateindividuals are notified and corrective action has been taken.

Note: A serious concealed danger exists when condition or work practice creates asubstantial probability of death, great bodily harm, or serious exposure to anindividual and the danger is not readily apparent to an individual who is likely to beexposed.

Supervisors Supervisors are responsible for:

Identifying and controlling access to a hazard and to prevent further danger toemployees and the public.

Notifying the necessary persons responsible for taking required action to correct thehazard.

Overview

Hazard Correction Responsibilities

12


Hazard Communication and Correction

Investigating and determining the root cause of any unsafe condition. Any source of hazard that is beyond the ability of the supervisor to correct should be immediately reported to Senior Management.

Taking temporary precautions until corrections can be made. Supervisors shall provide a status report to the Principal or Director when a temporary correction has been made.

Employees All employees are responsible for taking appropriate action to correct unsafe and unhealthy working conditions by immediately notifying appropriate management personnel of the conditions.

Maintenance & Operations Department The Maintenance & Operations Department is responsible for all repairs to buildings, grounds, and equipment with conditions that create hazards. Any safety related work order should be given the highest priority to ensure prompt correction.

To prevent danger to employees and the general public, access to any area that contains an immediate hazard or serious concealed danger should be controlled.

Supervisors, Directors, and/or Principals responsible for the area of operation where such conditions exist are responsible for informing employees verbally and in writing. The notification of any serious hazard should be done as soon as practical.

Only authorized personnel should be allowed access to areas with immediate hazards or serious concealed danger. Areas with such conditions should be properly secured to prevent any unauthorized access. Students should never be allowed access to such areas. Only when the condition has been corrected should access be permitted.

Examples of areas with immediate hazards include, but are not limited to, construction sites, confined spaces, chemical storage areas, transformers, high voltage areas, and electrical utility rooms.

Whenever any report of unsafe or unhealthy condition has been made, follow-up is essential to ensure that proper corrections are being or have been made.

Once a reported hazard has been corrected, Supervisors, Directors and/or Principals responsible for the area should conduct a safety evaluation to ensure that the hazard has been completely eliminated.

Controlling Access to Areas Containing Hazards

Hazard Correction Follow-Up

13


7 Training and Instruction

Section

This section of the OUSD IIPP discusses the methods used for training and instructing employees on safety issues. Information is presented about formal training, initial job instruction, and safety talks.

New Employees are required to attend an orientation that includes safety as a major topic.

The Director of Risk Management or designee is responsible for conducting the New Employee Safety Orientation training.

Safety training at the new Employee orientation shall include but not be limited to:

Injury Illness Prevention Plan

Bloodborne Pathogens

Hazard Communication and Integrated Pest Management Plan (IPM)

Slips, Trips, and Falls /Strains/Ladder Safety

Employee completion of this training shall be documented and such documentation shall be maintained in the employee’s personnel file.

When employees move to new occupations they are confronted with an entirely new environment and may be subjected to a new set of hazards. Safety training is essential for every employee, regardless as to whether they are a new hire or if they have been transferred from another area.

Initial Job Instruction (or Job Position Safety Orientation) refers to the on-the-job training given to new employees to prepare them to do a specific job. This type of safety training is an initial effort to generally acquaint employees with what they will need to know to perform their new positions safely. This type of training shall include topics such as general hazards, clean up and housekeeping responsibilities, and appropriate general safety rules.

Overview

New Employee Orientation

Initial Job Instruction

14


Training and Instruction

For non-routine, hazardous jobs it is advisable to cover the major job hazards with pre-job safety instructions, which include a specific orientation to the employee for a specific hazardous operation.

Supervisors assigning non-routine, hazardous jobs are responsible for conducting pre-job safety instructions. During this orientation, the Supervisor will cover specific hazards and precautions necessary for the job.

Information to be included during this type of training should include but not be limited to:

Safety equipment and personal protective equipment requirements.

Potential exposure to toxic materials.

Emergency procedures.

Physical hazards associated with the work area.

Planned Safety Talks Planned Safety Talks are one of several supervision tools for ongoing safety instructions designed to increase awareness of hazards, safe job procedures, and critical safety rules.

Essentially, such talks are short five to ten minute instructional talks between the first line Supervisor and one or more employees.

The subject of the talk is a specific topic like a safety rule or a particular hazard that is in need of emphasis.

Planned safety talks should be used whenever a new substance, process, procedure, or piece of equipment presenting a new hazard is introduced and whenever a Supervisor becomes aware of a new or previously unrecognized hazard.

Supervisors may schedule regular Safety Talks regarding other topics at a frequency that best suits the operations of the Department or affected employees.

Correctional Safety Talks When an employee is observed working in an unsafe manner, it is the responsibility of the Supervisor to correct the employee in a manner appropriate to the facts of the case. Correctional Safety Talks should be conducted in a friendly but firm manner.

Pre-Job Safety Instructions for Non-Routine Hazardous Jobs

Safety Talks

15


8 Section

Recordkeeping

This section of the OUSD IIPP describes the requirements for keeping records about safety evaluations, safety training, employee injuries and Supervisor investigations, and environmental/employee medical monitoring.

Safety evaluation documents shall:

Be maintained by the Risk Management Office.

Include the name of the person(s) conducting the evaluation.

Include any unsafe conditions or work practices.

Include corrective actions.

Be maintained for no less than five years.

The following pertains to documents related to employee injuries.

The Director of Risk Management or designee shall maintain employee injury reports and supervisor accident investigation reports.

Copies of Employee injury reports and Supervisor accident investigation reports will be maintained by the Risk Management Office and current workers compensation insurance carrier.

The Director of Risk Management or designee will maintain environmental and/or employee medical monitoring documentation for a period of no less than thirty years when special monitoring is required through the pre-determined job description and associated risk assessment as well as when required through incident exposure.

Overview

Safety Evaluation Documentation

Employee Injury Reports and Supervisor Accident Investigation Reports

Environmental/Employee Medical Monitoring

16


Appendix A


EMPLOYEE MANDATORY TRAININGS

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Accident Investigation X X Accident Procedures X X X X X X X AED (Automated External Defibrillators) X X X X X X X Asbestos Exposure (AHERA) X X Blood Borne Pathogen/Universal Precautions X Brake Inspections X Bus Passes/Sonar Z Pass X Cell Phones X X X X X X X Child Safety Restraint Systems (CSRS) X X X X X X Confidentiality X X X X X X X Defensive Driving X Drug and Alcohol X X X X X X X Earthquake/Fire Evacuations X X X X X X X Electrical/ Fire Safety X X Ergonomics X X X X X X X Food Handling X Integrated Pest Management X X X X X X X Ladder Safety X X X Lead Exposure X X Liability Awareness X Lock Out/Tag Out X Mandated Reporting X X X X X X X Mirrors X X X Personal Protective Equipment X X X Proper Lifting Techniques X X X X Railroad Crossings X Reduced Visibility X X X Safety Data Sheets X X X X X X X School Bus Idling X Sexual Harassment X X X X X X X Slips/Trips/Falls X X X X X X X Student Management X X X X X X Uniform Complaint Procedure X X X X X X X Vehicle Code 22112 X Workers Comp Reporting X X X X X X X Youth Suicide Awareness and Prevention X X X X X X X

Appendix A


Appendix B

ORANGE UNIFIED SCHOOL DISTRICT WORKERS’ COMPENSATION PROCEDURES

1. If the injury is serious, call 911 and contact Risk Management at ext 5390immediately.

2. Upon notification of injury/illness, provide injured worker with Report of Injuryor Illness Packet and complete a Supervisor’s Investigational Report of Injury.

FORMS AND INSTRUCTIONS:Employee’s Report of Injury or Illness Packet

• Employer provides to Injured Worker, Injured Worker signs cover page andreturns to Employer.

Workers’ Compensation Claim Form • Employee retains Notices (Pages 1-3) and completes Employee Section.• Employer completes Employer Section and provides Injured Worker with

completed Employee Copy.Facts about Workers’ Compensation

• Employee retains.Notice of WellComp Medical Provider Network

• Employee retains.

Supervisor’s Report of Injury • Supervisor completes and signs form. (e.g., Principal or AP)

3. If employee seeks medical treatment, contact Risk Management at ext 5390 to obtain referral to industrial clinic.

4. Scan all completed forms to Risk Management at [email protected] and [email protected] and mail originals to: Risk Management

5. Work Statuses:• A work status indicating “Full Duties” and/or “No Restrictions” must be

received PRIOR to the employee reporting to work.• Any restrictions must be cleared by Risk Management PRIOR to the

employee reporting to work.

mailto:[email protected]

ORANGE UNIFIED SCHOOL DISTRICT (OUSD) Risk Management Department 1401 N. Handy St., Orange, CA 92867 Phone (714) 628-5390 Fax (714) 628-4186

911 MAJOR ACCIDENT/INCIDENT PROTOCOL TITLE 8 CCR – EMPLOYER REQUIREMENT All Employers in the State of California are required to immediately report by telephone to the nearest Cal/OSHA office any serious injury or illness, or death, of an employee occurring in a place of employment or in connection with any employment. All calls to 911 or emergency medical services MUST be reported to Cal/OSHA as soon as practically possible but no longer than 8 hours after the employer knows or should have known of the incident.

PROCEDURES

STEPS ACTION TO BE TAKEN

1 Call 911 if an employee suffers a serious injury or illness

2 Immediately notify your site Administrator or Front Office of the incident

3 School Site Staff MUST inform Risk Management at 714-628-5390, of the incident and provide them with as much information as possible

4 During regular business hours (7:30am to 4:30pm), Risk Management Staff will contact Cal/OSHA to report the incident

5* After hours (4:30pm – 7:30am), Holiday and weekend incidents MUST be reported immediately to OUSD Security at 714-936-3271 or 714-628-4573 please provide as much information as possible about the incident

6 Provide all injured workers with a Report of Injury Packet (Workers Compensation Packet) as soon as the site is notified or becomes aware of the injury/illness.

7 Return all completed forms to Risk Management as soon as possible for processing. Feel free to scan copies to Marilyn Paz (W/C alpha A – M) at [email protected] or Alicia Herrera (W/C alpha N – Z) at [email protected] and mail originals to the Risk Management Department

* Security Staff will contact the designated Administrator with the pertinent information received. It will be the Administrators responsibility to file the report of incident with Cal/OSHA at 714-558-4451, as soon as possible but no later than 8 hours from the time of incident.

IMPORTANT – IN CASE OF AN EMERGENCY FOLLOW STEPS 1 - 5; DO NOT WAIT FOR THE REPORT OF INJURY PACKET TO BE COMPLETED BEFORE NOTIFYING RISK

MANAGEMENT OR OUSD SECURITY



Page 2

ORANGE UNIFIED SCHOOL DISTRICT CAL/OSHA CALL SHEET

714-558-4451

SITE NAME ADDRESS OF INJURY/INCIDENT DISTRICT MAILING ADDRESS WILL EMPLOYEE

BE KEPT OVERNIGHT:

1401 N. Handy St. Orange, CA, 92867

DATE OF INJURY

TIME OF INJURY

EMPLOYEE FULL NAME DATE OF BIRTH

EMPLOYEE JOB TITLE/POSITION

EMPLOYEE SSN: EMPLOYEE HOME ADDRESS EMPLOYEE PHONE

NUMBER NAME OF HOSPITAL WHERE EMPLOYEE WAS TAKEN

DESCRIBE HOW THE INJURY OCCURRED

DESCRIBE THE INJURIES SUSTAINED BY EMPLOYEE

SUPERVISORS FULL NAME SUPERVISORS

PHONE NUMBER NAME OF EMPLOYEE REPORTING INCIDENT TO CAL/OSHA

DATE OF REPORT TO CAL/OSHA

TIME OF REPORT TO CAL/OSHA

CAL/OSHA SAFETY INSPECTOR’S NAME NOTES

ORANGE UNIFIED SCHOOL DISTRICT Supervisor’s Investigation Report of Injury

COMPLETE AS SOON AS POSSIBLE

WORKERS’ COMPENSATION INSTRUCTIONS: 1. Complete this Report and email to [email protected] and [email protected] within 2 business

days of notice from employee.2. Provide injured employee with Report of Injury Illness packet and follow up for completion. Once received,

complete Employer Section of DWC 1 and provide injured worker with Notice and Employee Copy.3. Scan all forms to aherrera and marilynn and mail originals to Risk Management. DO NOT RETAIN ANY

COPIES AT YOUR SITE.4. NOTE: An employee who seeks medical treatment may NOT report to work without approval from Risk

Management. Name of Injured Worker: Site/Department: Date/Time of Injury:

Status (Check One): Full Time Part Time Volunteer Other

Date/Time of Report of Injury:

Position: (e.g., IA/Spec Ed, 3rd Grade Teacher) Start and End time of Position / Assignment:

Date Injury/Illness packet was provided to employee:

How was Injury/Illness packet provided to employee? Personally Mailed Home Other:

Date Injury/Illness packet was returned by employee:

Did Employee Seek Medical Attention? Yes No

Did employee lose any time from work after the date of injury? Yes No

If yes, list dates:

If employee has returned, list date of return: Check all unsafe conditions that existed: None Faulty/Unmarked Hazard Ergonomics Employee working out of classification Poor housekeeping Violation of safety rules Weather/Climate Horseplay Faulty Equipment/supplies Other:

Describe the steps recommended or taken to prevent a recurrence:

Explain, in specific detail, how the injury/illness occurred (include the specific campus location, what the employee was actually doing at the time of injury/illness, and what equipment/materials being used/carried, if any):

Outline specific body part which were affected and condition:

Is the employee’s account of the injury/exposure consistent with his/her job duties? Yes No If no, explain:

Prior to the employee’s injury/exposure, did he/she ever mention issues with the affected body part? Yes No If yes, explain:

List witnesses (full name/title), if any:

Describe what caused the situation to occur:

NOTE: If employee is transported to Emergency Room, call Risk Management at 714.628.5390 immediately.

Signature of Administrator completing this form: Type Administrator’s Name and Date of Signature



ORANGE UNIFIED SCHOOL DISTRICT Risk Management

1401 North Handy Street • Orange, CA 92867-4334 714.628.5390 • 714.628.4186 (Fax)

www.orangeusd.org

Mission Statement: Orange Unified School District, being committed to planning for continual improvement, will provide a curriculum and learning environment of excellence and high expectations to provide each student with the

opportunity and preparation to compete in the global economy.

REPORT OF INJURY OR ILLNESS PACKET

Employee Name:

Worksite:

Date of Injury:

Date Packet Was Provided to Employee:

Attached are the following forms:

Employee’s Report of Injury or Illness (return this form) Workers’ Compensation Claim Form (retain the Notice and return Form) Facts About Workers’ Compensation (retain for your records) Notice of WellComp Medical Provider Network (retain for your records)

I have received the forms outlined above and understand I must complete and return the Employee’s Report of Injury or Illness and the Workers’ Compensation Claim Form (Employee Section only). The Facts about Workers’ Compensation and WellComp Medical Provider Network is for my information.

Employee’s Signature: Date:

http://www.orangeusd.org/

ORANGE UNIFIED SCHOOL DISTRICT Employee’s Investigation Report of Injury

COMPLETE AS SOON AS POSSIBLE

Name: Site/Department: Date/Time of Injury:

SSN: Date of Birth: Date/Time of Report of Injury:

Position: (e.g., IA/Spec Ed, 3rd Grade Teacher) Start and End time of Position / Assignment:

Date Injury/Illness packet was received:

Date Forms were returned to site:

Employee Status (Check One): Full Time Part Time Volunteer Other

Explain, in specific detail, how the injury/illness occurred (include the specific campus location, what duties you were performing at the time of injury/illness, and what equipment/materials being used, if any):

Describe the injury/illness (affected body parts, condition):

Describe the steps recommended or taken to prevent a recurrence:

Describe any safety hazards you observed:

Have you every sustained an injury/illness to this body part before now? Yes No

If yes, please describe prior injury/illness to this body part?

I certify that the foregoing is true and correct:

Employee’s signature: Date:

Employer’s representative’s name:

Employer’s representative’s signature: Date:

Refusal of Medical Treatment

I understand that I have a right to seek medical treatment, however, I currently refuse that medical treatment for the event described above. I will advise my supervisor if I wish to see a medical provider for the event described above.

Employee’s signature: Date:

Confidential: Attorney/Client Work Product Privilege: This report is to be completed by school district employees. This form is a confidential, internal, document; its contents are not to be shared or copied for any persons who are not school district employees and/or their legal representatives.

Rev. 1/1/2016 Page 1 of 3

Workers’ Compensation Claim Form (DWC 1) & Notice of Potential Eligibility Formulario de Reclamo de Compensación de Trabajadores (DWC 1) y Notificación de Posible Elegibilidad If you are injured or become ill, either physically or mentally, because of your job, including injuries resulting from a workplace crime, you may be entitled to workers’ compensation benefits. Use the attached form to file a workers’ compensation claim with your employer. You should read all of the information below. Keep this sheet and all other papers for your records. You may be eligible for some or all of the benefits listed depending on the nature of your claim. If you file a claim, the claims administrator, who is responsible for handling your claim, must notify you within 14 days whether your claim is accepted or whether additional investigation is needed.

To file a claim, complete the “Employee” section of the form, keep one copy and give the rest to your employer. Do this right away to avoid problems with your claim. In some cases, benefits will not start until you inform your employer about your injury by filing a claim form. Describe your injury completely. Include every part of your body affected by the injury. If you mail the form to your employer, use first-class or certified mail. If you buy a return receipt, you will be able to prove that the claim form was mailed and when it was delivered. Within one working day after you file the claim form, your employer must complete the “Employer” section, give you a dated copy, keep one copy, and send one to the claims administrator.

Medical Care: Your claims administrator will pay for all reasonable and necessary medical care for your work injury or illness. Medical benefits are subject to approval and may include treatment by a doctor, hospital services, physical therapy, lab tests, x-rays, medicines, equipment and travel costs. Your claims administrator will pay the costs of approved medical services directly so you should never see a bill. There are limits on chiropractic, physical therapy, and other occupational therapy visits.

The Primary Treating Physician (PTP) is the doctor with the overall responsibility for treatment of your injury or illness. If you previously designated your personal physician or a medical group,

you may see your personal physician or the medical group after you are injured.

If your employer is using a medical provider network (MPN) or Health Care Organization (HCO), in most cases, you will be treated in the MPN or HCO unless you predesignated your personal physician or a medical group. An MPN is a group of health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information.

If your employer is not using an MPN or HCO, in most cases, the claims administrator can choose the doctor who first treats you unless you predesignated your personal physician or a medical group.

If your employer has not put up a poster describing your rights to workers’ compensation, you may be able to be treated by your personal physician right after you are injured.

Within one working day after you file a claim form, your employer or the claims administrator must authorize up to $10,000 in treatment for your injury, consistent with the applicable treating guidelines until the claim is accepted or rejected. If the employer or claims administrator does not authorize treatment right away, talk to your supervisor, someone else in management, or the claims administrator. Ask for treatment to be authorized right now, while waiting for a decision on your claim. If the employer or claims administrator will not authorize treatment, use your own health insurance to get medical care. Your health insurer will seek reimbursement from the claims administrator. If you do not have health insurance, there are doctors, clinics or hospitals that will treat you without immediate payment. They will seek reimbursement from the claims administrator.

Switching to a Different Doctor as Your PTP: If you are being treated in a Medical Provider Network (MPN), you may

switch to other doctors within the MPN after the first visit. If you are being treated in a Health Care Organization (HCO), you may

switch at least one time to another doctor within the HCO. You may switch to a doctor outside the HCO 90 or 180 days after your injury is reported to your employer (depending on whether you are covered by employer-provided health insurance).

If you are not being treated in an MPN or HCO and did not predesignate, you may switch to a new doctor one time during the first 30 days after your injury is reported to your employer. Contact the claims administrator to switch doctors. After 30 days, you may switch to a doctor of your choice if

Si Ud. se lesiona o se enferma, ya sea físicamente o mentalmente, debido a su trabajo, incluyendo lesiones que resulten de un crimen en el lugar de trabajo, es posible que Ud. tenga derecho a beneficios de compensación de trabajadores. Utilice el formulario adjunto para presentar un reclamo de compensación de trabajadores con su empleador. Ud. debe leer toda la información a continuación. Guarde esta hoja y todos los demás documentos para sus archivos. Es posible que usted reúna los requisitos para todos los beneficios, o parte de éstos, que se enumeran dependiendo de la índole de su reclamo. Si usted presenta un reclamo, l administrador de reclamos, quien es responsable por el manejo de su reclamo, debe notificarle dentro de 14 días si se acepta su reclamo o si se necesita investigación adicional. Para presentar un reclamo, llene la sección del formulario designada para el “Empleado,” guarde una copia, y déle el resto a su empleador. Haga esto de inmediato para evitar problemas con su reclamo. En algunos casos, los beneficios no se iniciarán hasta que usted le informe a su empleador acerca de su lesión mediante la presentación de un formulario de reclamo. Describa su lesión por completo. Incluya cada parte de su cuerpo afectada por la lesión. Si usted le envía por correo el formulario a su empleador, utilice primera clase o correo certificado. Si usted compra un acuse de recibo, usted podrá demostrar que el formulario de reclamo fue enviado por correo y cuando fue entregado. Dentro de un día laboral después de presentar el formulario de reclamo, su empleador debe completar la sección designada para el “Empleador,” le dará a Ud. una copia fechada, guardará una copia, y enviará una al administrador de reclamos. Atención Médica: Su administrador de reclamos pagará por toda la atención médica razonable y necesaria para su lesión o enfermedad relacionada con el trabajo. Los beneficios médicos están sujetos a la aprobación y pueden incluir tratamiento por parte de un médico, los servicios de hospital, la terapia física, los análisis de laboratorio, las medicinas, equipos y gastos de viaje. Su administrador de reclamos pagará directamente los costos de los servicios médicos aprobados de manera que usted nunca verá una factura. Hay límites en terapia quiropráctica, física y otras visitas de terapia ocupacional. El Médico Primario que le Atiende (Primary Treating Physician- PTP) es el médico con la responsabilidad total para tratar su lesión o enfermedad. Si usted designó previamente a su médico personal o a un grupo médico,

usted podrá ver a su médico personal o grupo médico después de lesionarse. Si su empleador está utilizando una red de proveedores médicos (Medical

Provider Network- MPN) o una Organización de Cuidado Médico (Health Care Organization- HCO), en la mayoría de los casos, usted será tratado en la MPN o HCO a menos que usted hizo una designación previa de su médico personal o grupo médico. Una MPN es un grupo de proveedores de asistencia médica quien da tratamiento a los trabajadores lesionados en el trabajo. Usted debe recibir información de su empleador si su tratamiento es cubierto por una HCO o una MPN. Hable con su empleador para más información.

Si su empleador no está utilizando una MPN o HCO, en la mayoría de los casos, el administrador de reclamos puede elegir el médico que lo atiende primero a menos de que usted hizo una designación previa de su médico personal o grupo médico.

Si su empleador no ha colocado un cartel describiendo sus derechos para la compensación de trabajadores, Ud. puede ser tratado por su médico personal inmediatamente después de lesionarse.

Dentro de un día laboral después de que Ud. Presente un formulario de reclamo, su empleador o el administrador de reclamos debe autorizar hasta $10000 en tratamiento para su lesión, de acuerdo con las pautas de tratamiento aplicables, hasta que el reclamo sea aceptado o rechazado. Si el empleador o administrador de reclamos no autoriza el tratamiento de inmediato, hable con su supervisor, alguien más en la gerencia, o con el administrador de reclamos. Pida que el tratamiento sea autorizado ya mismo, mientras espera una decisión sobre su reclamo. Si el empleador o administrador de reclamos no autoriza el tratamiento, utilice su propio seguro médico para recibir atención médica. Su compañía de seguro médico buscará reembolso del administrador de reclamos. Si usted no tiene seguro médico, hay médicos, clínicas u hospitales que lo tratarán sin pago inmediato. Ellos buscarán reembolso del administrador de reclamos. Cambiando a otro Médico Primario o PTP: Si usted está recibiendo tratamiento en una Red de Proveedores Médicos

Rev. 1/1/2016 Page 2 of 3

your employer or the claims administrator has not created or selected an MPN.

Disclosure of Medical Records: After you make a claim for workers' compensation benefits, your medical records will not have the same level of privacy that you usually expect. If you don’t agree to voluntarily release medical records, a workers’ compensation judge may decide what records will be released. If you request privacy, the judge may "seal" (keep private) certain medical records.

Problems with Medical Care and Medical Reports: At some point during your claim, you might disagree with your PTP about what treatment is necessary. If this happens, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, the steps to take depend on whether you are receiving care in an MPN, HCO, or neither. For more information, see “Learn More About Workers’ Compensation,” below.

If the claims administrator denies treatment recommended by your PTP, you may request independent medical review (IMR) using the request form included with the claims administrator’s written decision to deny treatment. The IMR process is similar to the group health IMR process, and takes approximately 40 (or fewer) days to arrive at a determination so that appropriate treatment can be given. Your attorney or your physician may assist you in the IMR process. IMR is not available to resolve disputes over matters other than the medical necessity of a particular treatment requested by your physician.

If you disagree with your PTP on matters other than treatment, such as the cause of your injury or how severe the injury is, you can switch to other doctors as described above. If you cannot reach agreement with another doctor, notify the claims administrator in writing as soon as possible. In some cases, you risk losing the right to challenge your PTP’s opinion unless you do this promptly. If you do not have an attorney, the claims administrator must send you instructions on how to be seen by a doctor called a qualified medical evaluator (QME) to help resolve the dispute. If you have an attorney, the claims administrator may try to reach agreement with your attorney on a doctor called an agreed medical evaluator (AME). If the claims administrator disagrees with your PTP on matters other than treatment, the claims administrator can require you to be seen by a QME or AME.

Payment for Temporary Disability (Lost Wages): If you can't work while you are recovering from a job injury or illness, you may receive temporary disability payments for a limited period. These payments may change or stop when your doctor says you are able to return to work. These benefits are tax-free. Temporary disability payments are two-thirds of your average weekly pay, within minimums and maximums set by state law. Payments are not made for the first three days you are off the job unless you are hospitalized overnight or cannot work for more than 14 days.

Stay at Work or Return to Work: Being injured does not mean you must stop working. If you can continue working, you should. If not, it is important to go back to work with your current employer as soon as you are medically able. Studies show that the longer you are off work, the harder it is to get back to your original job and wages. While you are recovering, your PTP, your employer (supervisors or others in management), the claims administrator, and your attorney (if you have one) will work with you to decide how you will stay at work or return to work and what work you will do. Actively communicate with your PTP, your employer, and the claims administrator about the work you did before you were injured, your medical condition and the kinds of work you can do now, and the kinds of work that your employer could make available to you.

Payment for Permanent Disability: If a doctor says you have not recovered completely from your injury and you will always be limited in the work you can do, you may receive additional payments. The amount will depend on the type of injury, extent of impairment, your age, occupation, date of injury, and your wages before you were injured.

Supplemental Job Displacement Benefit (SJDB): If you were injured on or after 1/1/04, and your injury results in a permanent disability and your employer does not offer regular, modified, or alternative work, you may qualify for a nontransferable voucher payable for retraining and/or skill enhancement. If you qualify, the claims administrator will pay the costs up to the maximum set by state law.

Death Benefits: If the injury or illness causes death, payments may be made to a

(Medical Provider Network- MPN), usted puede cambiar a otros médicos dentro de la MPN después de la primera visita.

Si usted está recibiendo tratamiento en un Organización de Cuidado Médico (Healthcare Organization- HCO), es posible cambiar al menos una vez a otro médico dentro de la HCO. Usted puede cambiar a un médico fuera de la HCO 90 o 180 días después de que su lesión es reportada a su empleador (dependiendo de si usted está cubierto por un seguro médico proporcionado por su empleador).

Si usted no está recibiendo tratamiento en una MPN o HCO y no hizo una designación previa, usted puede cambiar a un nuevo médico una vez durante los primeros 30 días después de que su lesión es reportada a su empleador. Póngase en contacto con el administrador de reclamos para cambiar de médico. Después de 30 días, puede cambiar a un médico de su elección si su empleador o el administrador de reclamos no ha creado o seleccionado una MPN.

Divulgación de Expedientes Médicos: Después de que Ud. presente un reclamo para beneficios de compensación de trabajadores, sus expedientes médicos no tendrán el mismo nivel de privacidad que usted normalmente espera. Si Ud. no está de acuerdo en divulgar voluntariamente los expedientes médicos, un juez de compensación de trabajadores posiblemente decida qué expedientes serán revelados. Si usted solicita privacidad, es posible que el juez “selle” (mantenga privados) ciertos expedientes médicos.

Problemas con la Atención Médica y los Informes Médicos: En algún momento durante su reclamo, podría estar en desacuerdo con su PTP sobre qué tratamiento es necesario. Si esto sucede, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, los pasos a seguir dependen de si usted está recibiendo atención en una MPN, HCO o ninguna de las dos. Para más información, consulte la sección “Aprenda Más Sobre la Compensación de Trabajadores,” a continuación.

Si el administrador de reclamos niega el tratamiento recomendado por su PTP, puede solicitar una revisión médica independiente (Independent Medical Review- IMR), utilizando el formulario de solicitud que se incluye con la decisión por escrito del administrador de reclamos negando el tratamiento. El proceso de la IMR es parecido al proceso de la IMR de un seguro médico colectivo, y tarda aproximadamente 40 (o menos) días para llegar a una determinación de manera que se pueda dar un tratamiento apropiado. Su abogado o su médico le pueden ayudar en el proceso de la IMR. La IMR no está disponible para resolver disputas sobre cuestiones aparte de la necesidad médica de un tratamiento particular solicitado por su médico.

Si no está de acuerdo con su PTP en cuestiones aparte del tratamiento, como la causa de su lesión o la gravedad de la lesión, usted puede cambiar a otros médicos como se describe anteriormente. Si no puede llegar a un acuerdo con otro médico, notifique al administrador de reclamos por escrito tan pronto como sea posible. En algunos casos, usted arriesg perder el derecho a objetar a la opinión de su PTP a menos que hace esto de inmediato. Si usted no tiene un abogado, el administrador de reclamos debe enviarle instrucciones para ser evaluado por un médico llamado un evaluador médico calificado (Qualified Medical Evaluator- QME) para ayudar a resolver la disputa. Si usted tiene un abogado, el administrador de reclamos puede tratar de llegar a un acuerdo con su abogado sobre un médico llamado un evaluador médico acordado (Agreed Medical Evaluator- AME). Si el administrador de reclamos no está de acuerdo con su PTP sobre asuntos aparte del tratamiento, el administrador de reclamos puede exigirle que sea atendido por un QME o AME.

Pago por Incapacidad Temporal (Sueldos Perdidos): Si Ud. no puede trabajar, mientras se está recuperando de una lesión o enfermedad relacionada con el trabajo, Ud. puede recibir pagos por incapacidad temporal por un periodo limitado. Estos pagos pueden cambiar o parar cuando su médico diga que Ud. está en condiciones de regresar a trabajar. Estos beneficios son libres de impuestos. Los pagos por incapacidad temporal son dos tercios de su pago semanal promedio, con cantidades mínimas y máximas establecidas por las leyes estales. Los pagos no se hacen durante los primeros tres días en que Ud. no trabaje, a menos que Ud. sea hospitalizado una noche o no puede trabajar durante más de 14 días.

Permanezca en el Trabajo o Regreso al Trabajo: Estar lesionado no significa que usted debe dejar de trabajar. Si usted puede seguir trabajando, usted debe hacerlo. Si no es así, es importante regresar a trabajar con su empleador actual tan

Rev. 1/1/2016 Page 3 of 3

spouse and other relatives or household members who were financially dependent on the deceased worker.

It is illegal for your employer to punish or fire you for having a job injury or illness, for filing a claim, or testifying in another person's workers' compensation case (Labor Code 132a). If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state.

Resolving Problems or Disputes: You have the right to disagree with decisions affecting your claim. If you have a disagreement, contact your employer or claims administrator first to see if you can resolve it. If you are not receiving benefits, you may be able to get State Disability Insurance (SDI) or unemployment insurance (UI) benefits. Call the state Employment Development Department at (800) 480-3287 or (866) 333-4606, or go to their website at www.edd.ca.gov.

You Can Contact an Information & Assistance (I&A) Officer: State I&A officers answer questions, help injured workers, provide forms, and help resolve problems. Some I&A officers hold workshops for injured workers. To obtain important information about the workers’ compensation claims process and your rights and obligations, go to www.dwc.ca.gov or contact an I&A officer of the state Division of Workers’ Compensation. You can also hear recorded information and a list of local I&A offices by calling (800) 736-7401.

You can consult with an attorney. Most attorneys offer one free consultation. If you decide to hire an attorney, his or her fee will be taken out of some of your benefits. For names of workers' compensation attorneys, call the State Bar of California at (415) 538-2120 or go to their website at www. californiaspecialist.org.

Learn More About Workers’ Compensation: For more information about the workers’ compensation claims process, go to www.dwc.ca.gov. At the website, you can access a useful booklet, “Workers’ Compensation in California: A Guidebook for Injured Workers.” You can also contact an Information & Assistance Officer (above), or hear recorded information by calling 1-800-736-7401.

pronto como usted pueda medicamente hacerlo. Los estudios demuestran que entre más tiempo esté fuera del trabajo, más difícil es regresar a su trabajo original y a sus salarios. Mientras se está recuperando, su PTP, su empleador (supervisores u otras personas en la gerencia), el administrador de reclamos, y su abogado (si tiene uno) trabajarán con usted para decidir cómo va a permanecer en el trabajo o regresar al trabajo y qué trabajo hará. Comuníquese de manera activa con su PTP, su empleador y el administrador de reclamos sobre el trabajo que hizo antes de lesionarse, su condición médica y los tipos de trabajo que usted puede hacer ahora y los tipos de trabajo que su empleador podría poner a su disposición.

Pago por Incapacidad Permanente: Si un médico dice que no se ha recuperado completamente de su lesión y siempre será limitado en el trabajo que puede hacer, es posible que Ud. reciba pagos adicionales. La cantidad dependerá de la clase de lesión, grado de deterioro, su edad, ocupación, fecha de la lesión y sus salarios antes de lesionarse.

Beneficio Suplementario por Desplazamiento de Trabajo (Supplemental Job Displacement Benefit- SJDB): Si Ud. se lesionó en o después del 1/1/04, y su lesión resulta en una incapacidad permanente y su empleador no ofrece un trabajo regular, modificado, o alternativo, usted podría cumplir los requisitos para recibir un vale no-transferible pagadero a una escuela para recibir un nuevo un curso de reentrenamiento y/o mejorar su habilidad. Si Ud. cumple los requisios, el administrador de reclamos pagará los gastos hasta un máximo establecido por las leyes estatales.

Beneficios por Muerte: Si la lesión o enfermedad causa la muerte, es posible que los pagos se hagan a un cónyuge y otros parientes o a las personas que viven en el hogar que dependían económicamente del trabajador difunto.

Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad laboral, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. (Código Laboral, sección 132a.) De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado.

Resolviendo problemas o disputas: Ud. tiene derecho a no estar de acuerdo con las decisiones que afecten su reclamo. Si Ud. tiene un desacuerdo, primero comuníquese con su empleador o administrador de reclamos para ver si usted puede resolverlo. Si usted no está recibiendo beneficios, es posible que Ud. pueda obtener beneficios del Seguro Estatalde Incapacidad (State Disability Insurance- SDI) o beneficios del desempleo (Unemployment Insurance- UI). Llame al Departamento del Desarrollo del Empleo estatal al (800) 480-3287 o (866) 333-4606, o visite su página Web en www.edd.ca.gov.

Puede Contactar a un Oficial de Información y Asistencia (Information & Assistance- I&A): Los Oficiales de Información y Asistencia (I&A) estatal contestan preguntas, ayudan a los trabajadores lesionados, proporcionan formularios y ayudan a resolver problemas. Algunos oficiales de I&A tienen talleres para trabajadores lesionados. Para obtener información importante sobre el proceso de la compensación de trabajadores y sus derechos y obligaciones, vaya a www.dwc.ca.gov o comuníquese con un oficial de información y asistencia de la División Estatal de Compensación de Trabajadores. También puede escuchar información grabada y una lista de las oficinas de I&A locales llamando al (800) 736-7401.

Ud. puede consultar con un abogado. La mayoría de los abogados ofrecen una consulta gratis. Si Ud. decide contratar a un abogado, los honorarios serán tomados de algunos de sus beneficios. Para obtener nombres de abogados de compensación de trabajadores, llame a la Asociación Estatal de Abogados de California (State Bar) al (415) 538-2120, o consulte su página Web en www.californiaspecialist.org.

Aprenda Más Sobre la Compensación de Trabajadores: Para obtener más información sobre el proceso de reclamos del programa de compensación de trabajadores, vaya a www.dwc.ca.gov. En la página Web, podrá acceder a un folleto útil, “Compensación del Trabajador de California: Una Guía para Trabajadores Lesionados.” También puede contactar a un oficial de Información y Asistencia (arriba), o escuchar información grabada llamando al 1-800-736-7401.

.

Rev. 1/1/2016

State of California Department of Industrial Relations DIVISION OF WORKERS’ COMPENSATION

WORKERS’ COMPENSATION CLAIM FORM (DWC 1)

Estado de California Departamento de Relaciones Industriales

DIVISION DE COMPENSACIÓN AL TRABAJADOR

PETITION DEL EMPLEADO PARA DE COMPENSACIÓN DEL TRABAJADOR (DWC 1)

Employee: Complete the “Employee” section and give the form to your employer. Keep a copy and mark it “Employee’s Temporary Receipt” until you receive the signed and dated copy from your employer. You may call the Division of Workers’ Compensation and hear recorded information at (800) 736-7401. An explanation of workers' compensation benefits is included in the Notice of Potential Eligibility, which is the cover sheet of this form. Detach and save this notice for future reference. You should also have received a pamphlet from your employer describing workers’ compensation benefits and the procedures to obtain them. You may receive written notices from your employer or its claims administrator about your claim. If your claims administrator offers to send you notices electronically, and you agree to receive these notices only by email, please provide your email address below and check the appropriate box. If you later decide you want to receive the notices by mail, you must inform your employer in writing.

Empleado: Complete la sección “Empleado” y entregue la forma a su empleador. Quédese con la copia designada “Recibo Temporal del Empleado” hasta que Ud. reciba la copia firmada y fechada de su empleador. Ud. puede llamar a la Division de Compensación al Trabajador al (800) 736- 7401 para oir información gravada. Una explicación de los beneficios de compensación de trabajadores está incluido en la Notificación de Posible Elegibilidad, que es la hoja de portada de esta forma. Separe y guarde esta notificación como referencia para el futuro.

Ud. también debería haber recibido de su empleador un folleto describiendo los benficios de compensación al trabajador lesionado y los procedimientos para obtenerlos. Es posible que reciba notificaciones escritas de su empleador o de su administrador de reclamos sobre su reclamo. Si su administrador de reclamos ofrece enviarle notificaciones electrónicamente, y usted acepta recibir estas notificaciones solo por correo electrónico, por favor proporcione su dirección de correo electrónico abajo y marque la caja apropiada. Si usted decide después que quiere recibir las notificaciones por correo, usted debe de informar a su empleador por escrito.

Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony.

Toda aquella persona que a propósito haga o cause que se produzca cualquier declaración o representación material falsa o fraudulenta con el fin de obtener o negar beneficios o pagos de compensación a trabajadores lesionados es culpable de un crimen mayor “felonia”.

Employee—complete this section and see note above Empleado—complete esta sección y note la notación arriba. 1. Name. Nombre. ___________________________________________________ Today’s Date. Fecha de Hoy. ____________________________________________ 2. Home Address. Dirección Residencial. _____________________________________________________________________________________________________ 3. City. Ciudad. _______________________________________ State. Estado. _____________________ Zip. Código Postal. ______________________________ 4. Date of Injury. Fecha de la lesión (accidente). ________________________________ Time of Injury. Hora en que ocurrió. ____________a.m. ___________p.m. 5. Address and description of where injury happened. Dirección/lugar dónde occurió el accidente. _______________________________________________________ _______________________________________________________________________________________________________________________________________ 6. Describe injury and part of body affected. Describa la lesión y parte del cuerpo afectada. ____________________________________________________________ _______________________________________________________________________________________________________________________________________ 7. Social Security Number. Número de Seguro Social del Empleado. _______________________________________________________________________________

8. Check if you agree to receive notices about your claim by email only. Marque si usted acepta recibir notificaciones sobre su reclamo solo por correo electrónico. Employee’s e-mail. _____________________________________ Correo electrónico del empleado. __________________________________________. You will receive benefit notices by regular mail if you do not choose, or your claims administrator does not offer, an electronic service option. Usted recibirá notificaciones de beneficios por correo ordinario si usted no escoge, o su administrador de reclamos no le ofrece, una opción de servicio electrónico. 9. Signature of employee. Firma del empleado. ________________________________________________________________________________________________

Employer—complete this section and see note below. Empleador—complete esta sección y note la notación abajo. 10. Name of employer. Nombre del empleador. ________________________________________________________________________________________________ 11. Address. Dirección. __________________________________________________________________________________________________________________ 12. Date employer first knew of injury. Fecha en que el empleador supo por primera vez de la lesión o accidente. ___________________________________________ 13. Date claim form was provided to employee. Fecha en que se le entregó al empleado la petición. ______________________________________________________ 14. Date employer received claim form. Fecha en que el empleado devolvió la petición al empleador._____________________________________________________ 15. Name and address of insurance carrier or adjusting agency. Nombre y dirección de la compañía de seguros o agencia adminstradora de seguros. _______________ _______________________________________________________________________________________________________________________________________ 16. Insurance Policy Number. El número de la póliza de Seguro.___________________________________________________________________________________ 17. Signature of employer representative. Firma del representante del empleador. ____________________________________________________________________ 18. Title. Título. _________________________________________ 19. Telephone. Teléfono. ___________________________________________________________

Employer: You are required to date this form and provide copies to your insurer or claims administrator and to the employee, dependent or representative who filed the claim within one working day of receipt of the form from the employee.

SIGNING THIS FORM IS NOT AN ADMISSION OF LIABILITY

Empleador: Se requiere que Ud. feche esta forma y que provéa copias a su compañía de seguros, administrador de reclamos, o dependiente/representante de reclamos y al empleado que hayan presentado esta petición dentro del plazo de un día hábil desde el momento de haber sido recibida la forma del empleado.

EL FIRMAR ESTA FORMA NO SIGNIFICA ADMISION DE RESPONSABILIDAD

Employer copy/Copia del Empleador Employee copy/Copia del Empleado Claims Administrator/Administrador de Reclamos Temporary Receipt/Recibo del Empleado

Notice Of Personal Chiropractic Or Personal Acupuncturist

If your employer or your employer’s insurer does not have a Medical Provider Network (MPN), you may be able to change your treating physician to your personal chiropractor (D.C.) or acupuncturist (L.AC.) following a work-related injury/illness. In order to be eligible to make this change, you must give your employer the name and business address of a personal D.C. or L.AC. in writing prior to the injury/illness. York generally has the right to select your treating physician within the first 30 days after your employer knows of your inju-ry/illness. After your employer or York has initiated your treatment with another physician during this period, you may then, upon request, have your treatment transferred to your personal D.C. or L.AC. You may use this form to notify your employer of your personal D.C. or L.AC., or your employer may have their own form. The D.C. or L.AC. must be your regular D.C. or L.AC. who has directed your treatment and retains your chiropractic records and history. If your employer has an MPN, you may only switch to a D.C. or L.AC. within the MPN. A chiropractor cannot be your treating physician after 24 visits. If you still require medical treatment thereafter, you will have to select a physician who is not a chiropractor. This prohibition shall not apply to visits for postsurgical physical medicine visits prescribed by the surgeon, or physician designated by the surgeon, under the postsurgical component of the Division of Workers’ Compensation’s Medical Treatment Utilization Schedule.

__________________________________________ ________ Name of chiropractor or acupuncturist (D.C., L.AC.)

__________________________________________________ (street address, city, state, zip code)

____________________________________________________ (telephone number)

Employee Name (Please Print):_____________________________

Employee’s Address:____________________________________

___________________________________________________

Employee’s Signature:___________________________________

Date:________________________________________________ Title 8, California Code of Regulations, section 9783.1 (Optional DWC Form 9783.1 Effective date July 1, 2014)

Pre-designation Of Personal Physician

In the event you sustain an injury or illness related to your employment, you may be treated for such injury/illness by your personal medical doctor (M.D) or doctor of osteopathic medicine (D.O.) or medical group if: You have health care insurance for injuries/illness that are not work related, the doctor is your regular physician, who shall be either a physician who has limited his or her practice of medicine to general practice or who is a board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist, or family practitioner, and has previously directed your medical treatment, and retains your medical records; your “personal physician” may be a medical group if it is a single corporation or partnership composed of licensed doctors of medicine or osteopathy, which operates an integrated multispecialty medical group provid-ing comprehensive medical services predominantly for non-occupational ill-nesses and injuries; prior to the injury your doctor agrees to treat you for work injuries or illnesses; prior to the injury you provided your employer the following in writing: (1) notice that you want your personal doctor to treat you for a work-related injury/illness, and (2) your personal doctor’s name and business address.

You may use this form, a form provided by your employer or provide all the information in writing to notify your employer if you wish to have your per-sonal medical doctor or a doctor osteopathic medicine treat you for a work-related injury/illness and the above requirements are met.

Notice Of Pre-designation Of Personal Physician Employee: Complete this section

Employer ________________________________________________

If I have a work-related injury or illness, I choose to be treated by: _______________________________________________________ (Name of doctor) (M.D., D.O., or medical group)

_______________________________________________________ (street address, city, state, zip)

_______________________________________________________ (telephone number)

Employee Name (please print): _________________________________

Employee’s Address:_________________________________________

Name of Insurance Company, Plan, or Fund providing health coverage for nonoccupational injuries or illnesses: _____________________________

________________________________________________________

Employee Signature:_______________________Date__________

Note to Employee: Unless you agree in writing, neither your employer or York may contact your personal physician to confirm a pre-designation. If your physician does not sign this form, other documentation that they agreed to be pre-designated prior to the injury will be required. If you agree, your employer or York may contact your personal physician to confirm this pre-designation, sign and date below:

Employee Signature__________________________________________

Employee #_________________________ Date_________________

Physician: I agree to this Pre-designation:

Signature:________________________________Date____________

(Physician or Designated Employee of the Physician)

The physician is not required to sign this form, however, if the physician or designated employee of the physician or medical group does not sign, other documentation of the physician’s agreement to be pre-designated will be required pursuant to Title 8, California Code of Regulations, section 9780.1(a)(3). (Optional DWC Form 9783 July 1, 2014)

© 7/1/14 YORK. All rights reserved

WHEN A WORK INJURY OCCURS…

Quickly seek first aid.

Call 9-1-1 for help immediately if emergency medical care is needed.

Immediately report injuries to your supervisor or employer representative at ____________________________________________

________________________________________________________________

Information & Assistance Office:______________________________

__________________________________________________________

__________________________________________________________

Employer MUST complete this information

York Risk Services Group, Inc. P.O. Box 619079

Roseville, CA 95661 Phone (866) 221-2402

Fax (866) 548-2637 Approved by Division of Workers’ Compensation

The Facts About Workers’

Compensation

State law limits certain medical services as of January 1, 2004. You should never receive a medical bill. If additional treatment is necessary, York will coordinate medical care that meets applicable treatment guidelines for the injury. The doctor may be a specialist for your specific type of injury, and he or she will be familiar with workers’ compensation requirements and will report promptly to York so your benefits can be paid.

The physician with overall responsibility for treating your injury/illness is your primary treating physician (PTP). The PTP decides what kind of medical care you need and if you have work restrictions. If necessary, the PTP will review your job description with you and your employer to define any limitation or restrictions that you may have. This doctor also is responsible for coordinating care between other medical providers and will write reports about any permanent impairment of bodily function(s) or the need for future medical care. Generally, your employ-er selects the PTP you will see for the first 30 days, but if you want to change doctors for any reason, ask your employer or York. They’re as interested as you are in your prompt recovery and return to work and will select a different doc-tor for you. If your employer has a Medical Provider Network (MPN) you will be directed to treat with a physician within the MPN and different rules apply re-garding changing your physician.

You can be treated by your personal physician or medical group immediately if you have health care insurance for injuries or illness that are not work related, and your physician agrees in advance to treat you for any work injuries/illnesses and has previously directed your treatment and retains your medical records and agrees, prior to your injury/illness, to treat you for workplace injuries/illnesses and you gave your employer your physician’s name and address in writing before the injury. You may use the form inside of this pamphlet or your employer may have a form for you to use.

If you give the name of your personal chiropractor or acupuncturist, different rules apply, and you may need to see an employer-selected physician first.

Temporary Disability Benefits: If you are not medically able to work for more than three days due to your work-related injury, counting weekends, you have a right to temporary disability (TD) payments to assist substituting your lost wages. After two weeks from reporting the injury, you will receive a check. If your employer has a salary continuation plan, your benefit may be included in your regular paycheck. TD is payable every 14 days until the doctor states you can return to work (Payments won’t be made for the first three days, though, unless you’re hospitalized as an inpatient or unable to work more than 14 days). The amount of the payments will be two-thirds of your average wage, subject to minimums and maximums set by the state legislature. Although the TD payment will not be the full amount of your regular paycheck, there are no deductions and the payments are tax-free. For injuries occurring on or after January 1, 2008, TD payments are limited to 104 compensable weeks within five years of date of injury. For a few long-term injuries such as chronic lung disease or severe burns, TD payments can last up to 240 weeks within five years from the date of injury. If you reach the maximum TD payment period before you can return to work or before your condition becomes permanent and stationary. See the “Other Bene-fits” section of this pamphlet for additional in information. A timely filing with Employment Development Department may result in additional State Disability benefits when TD benefits are delayed, denied, or terminated.

Permanent Disability: If your doctor says your injury will always leave you with some permanent impairment of bodily function(s), you may receive permanent disability (PD) payments. The amount depends on the doctor’s report, how much of the PD was directly caused by your work, and factors such as your age, occupation, type of injury, and date of injury. State law determines minimum and maximum amounts, and they vary by injury date. If you are entitled to PD, York will send you a letter explaining how the benefit was calculated. If the injury

What is workers’ compensation? Its purpose is to insure that an employee who is found to sustain an industrial injury or illness will be provided with benefits to medically cure or relieve them from the effects of the injury/illness, provide tem-porary compensation when they are medically unable to perform any occupational function, compensation for any residual handicap and/or impairment of bodily function, benefits for dependents if an employee dies as a result of an inju-ry/illness, protection from discrimination by his/her employer because of the injury/illness.

Am I Covered? Nearly every person employed in California is protected by workers’ compensation, however there are a few exceptions. People that are self-employed or volunteer workers may not be covered. Similar laws cover federal and maritime workers. York Risk Services Group (York) is your employer’s claims administrator. Your employer or York can answer any questions you might have about coverage.

What Does Workers’ Compensation Cover? If you have an injury/illness due to your job, it is covered. The cause can be a single event, like a fall or it can be due to repeated exposures, such as hearing loss due to constant loud noise. Injuries ranging from first-aid to serious accidents are covered. Even injuries related to a workplace crime, such as psychological or physical injuries, are covered under workers’ compensation. Some injuries that result from voluntary activity, such as off duty social or athletic activities may not be covered. Check with your employ-er or York if you have questions. Coverage begins the moment you start your job. There is no probationary period or wage rate.

Duty Of The Employee. Immediately notify your employer or York so you can get the medical help that you need without delay. If your injury is greater than a first-aid injury, your supervisor will give you a Claim Form (Form DWC-1) for you to describe where, when and how it happened. To submit a claim, fill out the “Employee” section of the DWC-1. Keep one copy of this form and give the remaining pages to your supervisor. Your employer will fill out the “Employer” section and return a signed and dated copy of the form to you. Your employer will keep a copy of this form and forward another to York. York is in charge of handling your claim and informing you about your eligibility for benefits.

Your claim benefits do not start until your employer knows about your injury, so report and file the DWC-1 as quickly as possible. California law requires your employer to authorize medical treatment within one working day of receipt of your Claim Form. Employers are liable for up to $10,000 in treatment pending a decision by York for a claim to be accepted or rejected. Waiting to report may delay workers’ compensation benefits. You may not receive benefits if you fail to file a claim within one year of the date of injury, the date you know the injury was work related, or the date benefits were last provided.

Duty of the Employer: Provide this form to every employee at the time of hire or by the end of their first pay period.

Within one working day, upon knowledge or notice from any source of a work injury/illness greater than first-aid, provide the employee with a Claim Form (DWC-1) and authorize medical treatment and report the claim to York Risk Services Group.

What are the benefits? You may be entitled to various kinds of benefits under California workers’ compensation law including:

Medical Care: Medical treatment that is reasonably required to cure or relieve the injured worker from the effects of the injury/illness. There is no deductible or co-payment. These medical benefits may include lab tests, physical therapy, hospi-tal services, medication and treatment by a doctor.

causes PD, the first payment of PD benefits is made within 14 days after the last payment of TD, unless your employer has offered you a position that pays at least 85% of your date of injury wages or if you are returned to a position that pays you 100% of the wages and, compensation paid to you on the date of injury, the PD would be paid after an Award issues.

Supplemental Job Displacement Benefit (SJDB): If you have a permanent whole person impairment, the eligibility for SJDB begins when your employer does not offer regular work, permanent, modified, or alternative work within 60 days of the receipt of a doctor’s Medical Maximum Improvement (MMI) report. This is a nontransferable voucher for education-related retraining and/or skill development at state-approved schools, tools, licensing, certifica-tion fees and other resources as possible benefits. If you qualify for the supple-mental job displacement benefit, York will provide a voucher up to a maximum of $6,000.

Death Benefits: If the injury/illness causes death, payments may be made to your dependents. State law sets these benefits and the total benefit depends on the number of dependents. The payments are made at the same rate as TD payments. In addition, workers’ compensation provides a burial allowance.

Discrimination: It a violation of Labor Code Section 132(a) and illegal for your employer to punish or fire you for having a workplace injury/illness, for filing a claim or for testifying in another person’s workers’ compensation case. If your employer is found guilty of discrimination, you would be entitled to increased benefits, reinstatement and reimbursement for lost wages and benefits.

Other Benefits: Sometimes people confuse workers’ compensation with State Disability Insurance (SDI). Workers’ compensation covers on-the-job injuries/ illnesses and is paid for by your employer or their insurance. On the other hand, SDI covers off-the-job injuries or sicknesses, and is paid for by deductions from your paycheck. If you are not getting workers’ compensation benefits, you may be able to get State Disability benefits. Contact the local office of the State Employment Development Department listed in the govern-ment pages of your phone book for more information.

You may be eligible to access the return-to-work fund, for the purposes of making supplemental payments to injured worker’s whose PD benefits are disproportionately low in comparison to their earnings loss. If you have ques-tions or think you qualify, contact the Information & Assistance office listed in this pamphlet or visit the DIR website at: www.dir.ca.gov.

If You Still Have Questions…ask your supervisor or employer representa-tive. Or contact York at the number indicated on workers’ compensation posters at work and on this brochure. You can also contact the State Division of Workers’ Compensation (DWC) and speak with an Information and Assis-tance Officer. These officers are available to review problems, answer ques-tions and provide additional written information about workers’ compensa-tion at no charge. The local office is listed below and posted at your work-place. You can also call 800-736-7401 or visit the DWC website at: http://www.dir.ca.gov/dwc.

WORKERS’ COMPENSATION FRAUD IS A FELONY

Anyone who makes or causes to be made any knowingly false or fraudu-lent material statement for the purpose of obtaining or denying workers’ compensation benefits or payments is guilty of a felony. Fines can be up

to $150,000 and imprisonment up to five years.

Aviso del Quiropráctico o Acupunturista Personal

If Si su empleador o aseguradora de su empleador no tiene una Red de Proveedores Médicos (MPN por sus siglas en inglés), usted puede cambiar que su médico tratante sea su quiropráctico (D.C., por sus siglas en inglés) o acupuntu-rista (L.AC., por sus siglas en inglés) personales luego de una lesión/enfermedad relacionada con el trabajo. A fin de ser elegible para hacer este cambio, usted debe dar a su empleador el nombre y dirección comercial de un quiropráctico o acupunturista personales por escrito antes de la lesión/enfermedad. York general-mente tiene el derecho de seleccionar a su médico tratante en el periodo de los primeros 30 días luego que su empleador se entere de su lesión/enfermedad. Después que su empleador o York hayan iniciado su tratamiento con otro médi-co durante este período, usted podrá, previa solicitud, hacer que su tratamiento sea transferido a su quiropráctico o acupunturista personales. Usted puede usar este formulario para notificar a su empleador acerca de su quiropráctico o acu-punturista personales, o su empleador puede tener su propio formulario. El D.C. o L.AC. deben ser su D.C. o L.AC. habituales que han dirigido su tratamiento y conservan sus registros e historia de quiropraxia. Si su empleador tiene una red de proveedores médicos (MPN, por sus siglas en inglés), usted sólo puede cam-biar a un D.C. o L.AC. dentro de la MPN. Si un quiropráctico no puede ser su médico tratante después de 24 visitas. Si aún requiere de tratamiento médico de ahí en adelante, tendrá que elegir un médico que no sea quiropráctico. Esta prohibición no se aplicará a las visitas de medicina física posquirúrgicos prescritos por el cirujano o médico designado por el cirujano, en el marco del componente posquirúrgica de la División de Tratamiento Médico programa de Utilización de Compensación para Trabajadores.

__________________________________________ ________ Nombre del quiropráctico o acupunturista (D.C., L.AC.)

__________________________________________________ (dirección calle, ciudad, estado, código postal)

____________________________________________________ (número de teléfono)

Nombre de empleado (Useletra de imprenta):__________________________

Dirección del empleado:____________________________________

______________________________________________________

Firma del empleado:___________________________________

Fecha:________________________________________________

Designación previa del médico personal

En el caso que usted sufra una lesión o enfermedad relacionada con su empleo, usted puede ser tratado por su lesión/enfermedad por su médico personal con grado de Doctor en Medicina (M.D.), Doctor en Osteopatía (D.O.) o grupo médico si: tiene seguro médico para lesiones/enfermedades que no están rela-cionadas al trabajo, el médico es su médico de cabecera, quien deberá ser un médico que ha limitado su práctica de medicina a la medicina general o que es un internista certificado por el consejo o internista, pediatra, gineco-obstetra , o médico de familia elegible por el consejo, y ha dirigido previamente su trata-miento médico, y conserva sus registros médicos; su "médico personal" puede ser un grupo médico si se trata de una corporación o asociación simple com-puesta de médicos licenciados en medicina u osteopatía, que opera un grupo médico de múltiples especialidades integradas que presta servicios médicos integrales sobre todo para enfermedades y lesiones no ocupacionales; antes de la lesión su médico está de acuerdo en darle el tratamiento para lesiones o enfer-medades ocupacionales; antes de la lesión usted proporcionó a su empleador por escrito lo siguiente: (1) notificación de que usted desea que su médico personal le trate por una lesión o enfermedad relacionada con el trabajo y (2) el nombre y dirección comerciales de su médico personal.

Usted puede utilizar este formulario, proporcionado por su empleador o propor-cionar toda la información por escrito para notificar a su empleador si desea que su médico personal con grado de Doctor en Medicina o Doctor en Osteopatía le trate por su lesión/enfermedad relacionada con el trabajo y se cumplen los requisitos mencionados anteriormente.

Aviso de Designación Previa de Médico Personal Empleado(a): Complete esta sección

Empleador ________________________________________________

Si tengo una enfermedad o lesión relacionada con el trabajo, elijo ser tratado(a) por: _______________________________________________________ (Nombre del médico) (M.D., D.O., o grupo médico)

_______________________________________________________ (dirección calle, ciudad, estado, código postal)

_______________________________________________________ (número de teléfono)

Nombre de empleado (Useletra de imprenta): __________________________

Dirección del empleado:________________________________________

Nombre de la Compañía de Seguros, Plan o Fondo que le proporciona cobertura de salud para lesiones o enfermedades no ocupacionales:_________________

___________________________________________________________

Firma del empleado:_______________________ Fecha: __________

Nota para el Empleado: A menos que usted esté de acuerdo por escrito, ni su empleador ni York pueden comunicarse con su médico personal para confirmar una designación previa. Si su médico no firma este formulario, será necesaria otra documentación que confirme la aceptación en ser designado antes de la lesión. Si usted está de acuerdo, su empleador o York pueden comunicarse con su médico personal para confirmar esta designación previa, firme y coloque la fecha a con-tinuación:

Firma del empleado__________________________________________

Empleado #_________________________ Fecha_________________

Médico: Acepto esta designación previa:

Firma:________________________________ Fecha:____________

(Médico o Empleado Designado del Médico)

No se exige que el médico firme este formulario; sin embargo, si el médico o empleado designado del

médico o grupo médico no firma, se exigirá otro documento de la aceptación del médico de la desig-

nación previa en conformidad con el Título 8, Código de Normas de California, sección 9780.1(a)(3)

© 01/JUL/2014 YORK. Todos los derechos reservados

CUANDO OCURRE UNA LESIÓN EN EL TRABAJO…

Busque rápidamente primeros auxilios.

Llame al 9-1-1 para solicitar ayuda inmediata, si es una emergen-cia, se requiere atención médica.

Informe inmediatamente las lesiones a su supervisor o repre-sentante del empleador en____________________________________

________________________________________________________________

Oficina de Información y Asistencia:______________________________

__________________________________________________________

__________________________________________________________

El empleador DEBE completar esta información

York Risk Services Group, Inc. P.O. Box 619079

Roseville, CA 95661 Teléfono (866) 221-2402

Fax (866) 548-2637

Aprobado por la División de Compensación del Trabajador

Información Acerca de

Compensación del

Trabajador

Usted nunca debe recibir una factura médica. Si el tratamiento adicional es necesario, York coordinará la atención médica que cumpla con las normas aplicables de tratamiento para la lesión. El médico puede ser un especialista para su tipo específico de lesión, deberá conocer los requisitos de compensación del trabajador e informará con prontitud a York de manera que se paguen sus beneficios.

El médico con la responsabilidad general del tratamiento de su lesión/enfermedad es el médico de atención primaria (PTP, por sus siglas en inglés). El PTP decide qué tipo de atención médica usted necesita y si usted tiene restricciones de trabajo. Si es necesario, el PTP revisará la descripción de su trabajo con usted y su empleador para definir cualquier limitación o restricción que usted pueda tener. Este médico también es responsable de coordinar la atención entre los demás proveedores de servicios médicos y, si es una lesión grave, escribirá los informes sobre cualquier discapacidad permanente de las fun-ciones corporales o la necesidad de atención médica en el futuro. Generalmente, su empleador selecciona al PTP que usted verá durante los primeros 30 días, pero si usted desea cambiar de médico por cualquier motivo, pregunte a su empleador o York. A su empleador le interesa tanto como a usted su pronta recuperación y retorno al trabajo y seleccionará a un médico diferente para usted. Si su empleador tiene una Red de Proveedores Médicos (MPN, por sus siglas en inglés), usted será dirigido a tratarse con un médico dentro de la MPN y se aplican reglas diferentes sobre cómo cambiar a su médico.

Usted puede ser tratado por su médico personal o grupo médico de inmediato si tiene seguro médico para lesiones o enfermedades que no estén relacionadas al trabajo, y si su médico estuvo de acuerdo por adelantado en darle el tratamiento para las lesiones o enfermedades ocupacionales y ha dirigido previamente su tratamiento y conserva sus registros médicos y está de acuerdo, antes de su lesión/enfermedad, en atenderle por sus lesiones o enfermedades ocupacionales, y usted entregó a su empleador el nombre de su médico y la dirección por escrito antes de la lesión. Usted puede utilizar el formulario

dentro de este folleto o su empleador puede tener un formulario para que usted lo utilice.

Si usted da el nombre de su quiropráctico o acupunturista personal, se aplican reglas diferentes, y usted puede necesitar ver primero a un médico seleccionado por el empleador.

Beneficios de discapacidad temporal: Si usted no es médicamente capaz de trabajar durante más de tres días debido a su lesión relacionada con el trabajo, contando los fines de semana, usted tiene el derecho a pagos de discapacidad temporal (TD, por sus siglas en inglés) para ayudarle en la sustitución de sus salarios perdidos. Después de dos semanas a partir de la presentación del informe de la lesión, usted recibirá un cheque. Si su empleador tiene un plan de continuación de salario, sus beneficios pueden ser incluidos en su cheque de pago habitual. TD se paga cada 14 días hasta que el médico declare que usted puede retornar al trabajo (sin embargo los pagos no se hacen durante los primeros tres días, a menos que usted esté hospitalizado o no pueda trabajar más de 14 días). El monto de los pagos será dos tercios de su salario promedio sujetos a los mínimos y máximos establecidos por la legislatura estatal. Aunque el pago por discapacidad temporal no será el monto total de su cheque de pago habitual, no hay deducciones y los pagos están libres de impuestos. Para lesiones que ocurren a partir del 1 de enero de 2008, los pagos por discapacidad temporal se limitan a 104 semanas compensables en el periodo de cinco años luego de la fecha de la lesión. Para unas pocas lesiones a largo plazo, tales como enfermedad pulmonar crónica o quemaduras severas, los pagos por discapacidad temporal pueden durar hasta 240 semanas en el periodo de cinco años a partir de la fecha de la lesión. Si usted alcanza el máximo pago por discapacidad temporal antes que usted pueda retornar al trabajo, su condición se convierte en permanente y estacionaria. Vea la sección "Otros Beneficios" de este folleto para más en la información. La presentación oportuna al Departamento de Desarrollo de Empleo puede dar lugar a beneficios Estatales de Discapacidad adicionales cuando los beneficios por discapacidad temporal se retrasan, deniegan o cancelan.

Discapacidad permanente: Si su médico dice que su lesión siempre le dejará con cierta discapacidad permanente de las funciones corporales, usted puede recibir pagos de discapacidad permanente (PD, por sus siglas en inglés). El monto depende del informe médico, la cantidad de discapacidad permanente que fue causada directamente por su trabajo, y factores como su edad, ocupación, tipo de lesión, y fecha de la lesión. La ley estatal determina los montos mínimos y máximos, y varían según la fecha de la lesión. Si usted tiene derecho a discapacidad permanente, York le enviará una carta explicando cómo se calculó el beneficio. Si la lesión causa discapacidad permanente, el primer pago vence en el periodo de 14 días a partir del pago final por discapacidad temporal, salvo que

¿Qué es la compensación del trabajador? Su propósito es asegurar que un empleado que sufre una lesión o enfermedad ocupacional reciba beneficios para curar o aliviar médicamente los efectos de la lesión/enfermedad, proporcionar compensación temporal, cuando el empleado sea médicamente incapaz de realizar cualquier función ocupacional, compensación por cualquier discapacidad residual y/o impedimento de la función corporal, beneficios para los dependientes si un empleado fallece como consecuen-cia de una lesión/enfermedad, protección contra la discriminación de su empleador debido a la lesión/enfermedad.

¿Tengo cobertura? Casi todas las personas empleadas en California están protegidas por la compensación del trabajador; sin embargo hay algunas excepciones. Las personas que trabajan de manera independiente o trabajadores voluntarios no pueden tener cober-tura. Leyes similares cubren a los trabajadores federales y marítimos. Su empleador está lícitamente autoasegurado. York Risk Services Group (York) es el administrador de reclamaciones de su empleador. Su empleador o York pueden responder a cualquier pregunta que usted tenga acerca de la cobertura.

¿Qué cubre la Compensación del Trabajador? Si usted tiene una lesión/enfermedad debido a su trabajo, usted tiene cobertura. La causa puede ser un solo evento, como una caída, o puede ser debido a exposiciones repetidas, como la pérdida de audición debido al ruido fuerte y constante. Las lesiones que varían desde primeros auxilios a accidentes graves tienen cobertura. Incluso las lesiones relacionadas con un delito en el lugar de trabajo, tales como lesiones físicas o psicológicas, tienen cobertura de la compensación del trabajador. Algunas lesiones que resultan de actividades voluntarias, como actividades sociales o deportivas fuera del servicio, no pueden tener cobertura. Consulte con su empleador o York si usted tiene preguntas. La cobertura comienza en el momento de empezar su trabajo. No hay periodo de prueba o tarifa de salario.

Deber del Empleado: Notifique inmediatamente a su empleador o York de manera que usted pueda conseguir la ayuda médica que usted necesita sin demora. Si su lesión es mayor que una lesión de primeros auxilios, su supervisor le dará un Formulario de Reclamación (Formulario DWC-I) para que usted describa dónde, cuándo y cómo sucedió. Para presentar una reclamación, complete la sección "Empleado" del DWC-I. Guarde una copia de este formulario y entregue las páginas restantes a su supervisor. Su empleador deberá completar la sección "Empleador" y entregarle una copia firmada y fechada. Su empleador conservará una copia de este formulario y enviará otra a York. York está a cargo de manejar su reclamación e informarle a usted acerca de su elegibilidad para recibir beneficios.

Sus beneficios de reclamación no se inician hasta que su empleador se entere de su lesión, por ello informe y presente el DWC-I tan pronto como sea posible. Las leyes de California exigen que su empleador autorice el tratamiento médico en el plazo de un día hábil luego de haber recibido su Formulario de Reclamación. Los empleadores son responsables de un máximo de $10,000 por el tratamiento en espera de una decisión de York sobre la acepta-ción o rechazo de una reclamación. Esperar el informe puede retrasar los beneficios de indemnización del trabajador. Usted no puede recibir beneficios si no presenta una reclamación en el periodo de un año luego de la fecha de la lesión, la fecha en que usted se entera que su lesión era ocupacional, o la fecha en que se proporcionaron por última vez los beneficios.

Deber del Empleador: Entregue este formulario a todos los empleados en el momento de la contratación o al final de su primer período de pago.

En el periodo de un día hábil, al conocer o recibir aviso por parte de cualquier fuente de una lesión/enfermedad ocupacional mayor que primeros auxilios, entregue al empleado un formulario de reclamación (DWC-1) y autorice tratamiento médico e informe la

reclamación a York Risk Services Group.

¿Cuáles son los beneficios? Usted puede tener derecho a diversos tipos de beneficios en virtud de la ley de compensación del trabajador de California, incluyendo:

Atención médica: El tratamiento médico que sea razonablemente necesario para curar o aliviar al trabajador lesionado de los efectos de la lesión/enfermedad. No hay deducible ni copago. Estos beneficios médicos pueden incluir análisis de laboratorio, terapia física,

servicios de hospital, medicamentos y tratamiento por un médico. La ley estatal limita

su empleador le haya ofrecido a usted un puesto de trabajo que pague un mínimo del 85% del salario de su fecha de lesión o si regresó a un puesto de trabajo que paga el 100% del salario y, las prestaciones pagadas a usted en la fecha de la lesión, la discapaci-dad permanente se pagará después que se emita la adjudicación.

Beneficio complementario por desplazamiento laboral (SJDB, por sus siglas en inglés): Si usted tiene una discapacidad permanente, la elegibilidad para el beneficio complementario por desplazamiento laboral comienza cuando su empleador no tiene trabajo regular, permanente, modificado o alternativo en un periodo de 60 días a partir del recibo de un informe de Mejoría Máxima Médica (MMI por sus siglas en inglés). Esto es un vale no transferible para cuotas de reentrenamiento y/o desarrollo de habilidades relacionadas con la educación en escuelas autorizadas por el estado, herramientas, autorización de licencias y certificación así como otros recursos como beneficios posibles. Si usted califica para el beneficio complementario por desplazamiento laboral, York ofrecerá un vale por un monto máximo de $6,000.

Beneficios por defunción: Si la lesión/enfermedad causa la muerte, los pagos se pueden efectuar a sus dependientes. Las leyes estatales establecen estos beneficios y el beneficio total depende del número de dependientes. Los pagos se hacen a la misma tarifa que los pagos por discapacidad temporal. Además, la compensación del trabajador ofrece un monto asignado por concepto de sepelio.

Discriminación: Es una infracción del Código Laboral, Sección 132(a) e ilegal que su empleador le castigue o despida por sufrir una lesión/enfermedad ocupacional, presen-tar una reclamación o atestiguar en el caso de compensación del trabajador de otra persona. Si su empleador es declarado culpable de discriminación, usted tendría derecho a un aumento de beneficios, restitución y reembolso de los salarios y benefi-cios perdidos.

Otros beneficios: A veces se confunde la compensación del trabajador con el Seguro Estatal de Discapacidad (SDI, por sus siglas en inglés). La compensación del trabajador las lesiones/enfermedades ocupacionales, y es pagada por su empleador o su asegura-dora. Por otro lado, el SDI cubre las lesiones o enfermedades ocurridas fuera del trabajo, y es pagado mediante deducciones de su cheque de pagos. Si usted no está recibiendo beneficios de compensación del trabajador, puede ser capaz de obtener los beneficios de Discapacidad del Estado. Póngase en contacto con la oficina local del Departamento de Desarrollo de Empleo del Estado que aparece en las páginas guberna-mentales de su directorio telefónico para obtener más información.

Puede ser elegible para acceder al fondo de regreso al trabajo, con el fin de hacer pagos complementarios a trabajadores lesionados cuyos beneficios de discapacidad permanente son desproporcionalmente bajos en comparación con su pérdida de ganancias. Si tiene alguna pregunta o cree que califica, póngase en contacto con la oficina de Información y asistencia indicada en este folleto o visite el sitio web de DIR en: www.dir.ca.gov.

Si usted todavía tiene preguntas... pregunte a su supervisor o representante del empleador. O póngase en contacto con York llamando al número que se indica en los afiches de compensación del trabajador colocados en el trabajo y en este folleto. También puede comunicarse con la División Estatal de Compensación del Trabajador (DWC, por sus siglas en inglés) y hablar con un Funcionario de Información y Asisten-cia. Estos funcionarios están disponibles para examinar los problemas, responder preguntas y proporcionar información adicional escrita sobre la compensación del trabajador de manera gratuita. La oficina local se muestra a continuación y se publicará en su lugar de trabajo. Usted también puede llamar al 800-736-7401 o visitar el sitio web de DWC: http://www.dir.ca.gov/dwc

EL FRAUDE DE COMPENSACIÓN LABORAL ES UN DELITO GRAVE

Toda persona que haga o disponga que se haga una declaración material deliberadamen-te falsa o fraudulenta con el fin de obtener o denegar los beneficios o pagos de la

compensación laboral es culpable de un delito grave. Las multas pueden ser de hasta un máximo de $150,000 y el encarcelamiento de hasta un máximo de cinco años.

Welcome to WellComp

Your employer has elected to provide you with the choice of a broad scope of medical services for work-related injuries and illnesses by implementing a Medical Provider Network (MPN), called WellComp. WellComp delivers quality medical care through your choice of a provider who is part of an exclusive network of healthcare providers, each of whom possess a deep understanding of the California workers’ compensation system and the impact their decisions have on you. Your employer has received the approval from the State of California to cover your workers’ compensation medical care needs through the WellComp Network. You are automatically covered by the WellComp Network if your date of injury or illness is on or after your employer’s MPN implementation date and if you have not properly pre-designated a personal physician prior to your injury or illness.

n Initial CareIn case of an emergency, you should call 911 or go to the closest emergency room.

In the event that you experience a work-related injury or illness, immediately notify your supervisor and obtain medical authorization from your employer to designate an initial care provider within the network. If you are unable to reach your supervisor or employer, please contact the patient services department at WellComp. For non-emergency services, the MPN must ensure that you are provided an appointment for initial treatment within 3 business days of your employer’s or MPN receipt of request for treatment within the MPN.

In the event that you have an injury or illness, you may carry this pamphlet with you to present to your medical service provider for access to care.

n Subsequent CareIf you still need treatment following your initial evaluation, you may be treated by a physician of your choice, or the initial physician may refer you to a medically and geographically appropriate specialist within the network who can provide the appropriate treatment for your injury or condition. Your employer is required to provide you with at least three physicians of each specialty expected to treat common injuries experienced by injured employees based on your occupation or industry. These physicians will be available within 30 minutes or 15 miles of your workplace or residence and specialists will be available within 60 minutes or 30 miles of your residence or workplace. For a directory of providers, please visit www.WellComp.com or call WellComp Patient Services.

n Emergency CareIn an emergency, defined as a medical condition starting with the sudden onset of severe symptoms that without immediate medical attention could place your health in serious jeopardy, go to the nearest healthcare provider regardless of whether they are a WellComp participant. If your injury is work-related, advise your emergency care provider to contact WellComp to arrange for a transfer of your care to a WellComp provider at the medically appropriate time.

n Hospital and Specialty CareYour primary treating provider in the WellComp Network can make all of the necessary arrangements and referrals for specialists, inpatient hospital, outpatient surgery center services, and ancillary care services.

n Choosing a Treating PhysicianIf you still require treatment after your initial evaluation with your employer’s designated provider, you may access the WellComp Directory and select an appropriate physician of your choice who can provide the necessary treatment for your condition or illness. For assistance determining physician options, please contact the Medical Access Assistant in the WellComp Patient Services Department or discuss your options with your initial care provider.

n Scheduling AppointmentsIf you are having difficulty scheduling an appointment with your initial provider or subsequent provider, please contact the Medical Access Assistant in the WellComp Patient Services Department or your Claims Examiner.

n Changing Primary Treating PhysicianIf you find it necessary to change your treating physician and it is determined that you require ongoing medical care for your injury or illness, you may select a new physician from the WellComp Directory and schedule an appointment. Once your appointment is scheduled, immediately contact WellComp Patient Services who will then coordinate the transfer of your medical records to your new provider.

n Obtaining a Specialist ReferralAs long as you continue to require medical treatment for your injury or illness, there are alternatives for obtaining a referral to a specialist:

1. Your primary treating provider in the WellComp Network can make all of the necessary arrangements for referrals to a specialist. This referral will be made within the network or outside of the network if needed.

2. You may select an appropriate specialist by accessing the WellComp Directory.

3. You may contact your Medical Access Assistants in the WellComp Patient Services who can help coordinate necessary arrangements.

If your primary treating provider makes a referral to a type of specialist not included in the network, you may select a specialist from outside the network.

For non-emergency specialist services, the MPN must ensure that you are provided an appointment within 20 business days of your employer’s or MPN receipt of a referral to a specialist within the MPN.

n Continuity of CareWhat if I am being treated by a WellComp doctor and the doctor leaves WellComp?

Your employer has a written “Continuity of Care” Policy that may allow you to continue treatment with your doctor if your doctor is no longer actively participating in WellComp.If you are being treated for a work-related injury in the WellComp Network and your doctor no longer has a contract with WellComp, your doctor may be allowed to continue to treat you if your injury or illness meets one of the following conditions:

• (Acute) A medical condition that includes a sudden onset of symptoms that require prompt care and has a duration of less than 90 days.

• (Serious or Chronic) Your injury or illness is one that is serious and continues for at least 90 days without full cure or worsens and requires ongoing treatment. You may be allowed to be treated by your current treating doctor for up to one year, until a safe transfer of care can be made.

• (Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less.

• (Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN contract termination date.

If any of the above conditions exist, WellComp may require your doctor to agree in writing to the same terms he or she agreed to when he or she was a provider in the WellComp Network. If the doctor does not, he or she may not be able to continue to treat you.

If the contract with your doctor was terminated or not renewed by WellComp for reasons relating to medical disciplinary cause or reason, fraud or criminal activity, you will not be allowed to complete treatment with that doctor. For a complete copy of the Continuity of Care policy in English or Spanish, please visit www.WellComp.com or call WellComp Patient Services.

n Transfer of Ongoing CareWhat if you are already being treated for a work-related injury before the WellComp Network begins?

Your employer has a “Transfer of Care” policy which describes what will happen if you are currently treating for a work-related injury with a physician who is not a member of the WellComp Network. If your current treating doctor is a member of WellComp, then you may continue to treat with this doctor and your treatment will be under WellComp. If your current treating physician is not a participating physician within WellComp and you have not yet been transferred into the MPN, your physician can make referrals to providers within or outside the MPN. Your current doctor may be allowed to become a member of WellComp.

You will not be transferred to a doctor in WellComp if your injury or illness meets any of the following conditions:

• (Acute) The treatment for your injury or illness will be completed in less than 90 days.

• (Serious or Chronic) Your injury or illness is one that is serious and continues without full cure or worsens over 90 days. You may be allowed to be treated by your current treating doctor for up to one year from the date of receiptofthenotificationthatyouhaveaseriouschroniccondition.

• (Terminal) You have an incurable illness or irreversible condition that is likely to cause death within one year or less. Treatment will be provided for the duration of the terminal illness.

• (Pending Surgery) You already have a surgery or other procedure that has been authorized by your employer or insurer that will occur within 180 days of the MPN effective date.

• Foracompletecopyof theTransferofCarepolicy inEnglishorSpanish,please visit www.WellComp.com or call WellComp Patient Services.

n Care Transfer DisputesNotice of determination, from the employer or claims examiner, shall be sent to the covered employee’s address and a copy of the letter shall be sent to the covered employee’s primary treating physician. The notification shall be written in English and Spanish and use layperson’s terms to the maximum extent possible. If WellComp is going to transfer your care and you disagree, you may ask your treating doctor for a report that addresses whether you are in one of the categories listed above. Your treating physician shall provide a report to you within twenty calendar days of the request. If the treating physician fails to issue the report, then you will be required to select a new provider from within the MPN. If either WellComp or you do not agree with your treating doctor’s report, this dispute will be resolved according to Labor Code Section 4062. You must notify WellComp Patient Services Department if you disagree with this report.

If your treating doctor agrees that your condition does not meet one of those listed above, the transfer of care will go forward while you continue to disagree with the decision. If your treating doctor believes that your condition does meet one of those listed above, you may continue to treat with him or her until the dispute is resolved.

Access to Medical Care

This pamphlet is not required to receive medical services

Second Opinion, Third Opinion and Independent Medical Review Process:If you disagree with your doctor or do not like your doctor for any reason, you may always choose another doctor in the MPN.

n Obtaining Second and Third OpinionsIf you disagree with the diagnosis or treatment plan determined by your treating physician or your second opinion physician, and would like a second or third opinion, you must take the following steps:ü Notify your claims examiner who will provide you with a

regional area listing of physicians and/or specialists within the WellComp Network who have the recognized expertise to evaluate or treat your injury or condition.

ü Select a physician or specialist from the list.ü Within 60 days of receiving the list, schedule an

appointment with your selected physician or specialist from the list provided by your claims examiner. Should you fail to schedule an appointment within 60 days, your right to seek another opinion will be waived.

ü Inform your claims examiner of your selection and the appointment date so that we can ensure your medical records can be forwarded in advance of your appointment date. You may also request a copy of your medical records.

ü You will be provided information and a request form regarding the Independent Medical Review (IMR) process at the time you select a third opinion physician. Information about the IMR process can be found in the MPN Employee Handbook.

If the Second/Third opinion doctor feels that your injury is outside of the type of injury he or she normally treats, the doctor’s office will notify your employer or insurer. You will get another list of MPN doctors or specialists so you can make another selection.

If the 2nd/3rd opinion doctor agrees with your need for a treatment or test, you may be allowed to receive that recommended treatment or test from a provider inside or outside the MPN, including the 2nd or 3rd opinion physician.

n Obtaining an Independent Medical Review (IMR)If you disagree with the diagnosis or treatment plan determined by the third opinion physician, you may file the completed MPN Independent Medical Review Application form with the Administrative Director of the Division of Workers’ Compensation. You may contact your claims examiner or the WellComp Patient Services Department for information about the Independent Medical Review process and the form to request an Independent Medical Review.

If the second opinion, third opinion or IMR agrees with your treating doctor, you will need to continue to receive medical treatment with a network physician if MPN contains a physician who can provide the recommended treatment. If the IMR does not agree with your treating network physician, you will be allowed to receive that medical treatment from a provider either inside or outside of the WellComp Network.

Any physician chosen outside of the WellComp Network must be within reasonable geographic area. The treatment or diagnostic test is limited to the recommendation of the MPN/ IMR.

n Treatment Outside of the Geographic AreaWellComp has providers throughout California. If a situation arises which takes you out of the coverage area, such as temporary work, travel for work, or living temporarily or permanently outside the MPN geographic service area, please contact the WellComp Patient Services Department, your claims examiner, or your primary treating provider, and they will provide you with a selection of at least 3 approved out-of-network providers from whom you can obtain treatment or get second and third opinions from the referred selection of physicians.

Covered Medical Services: The following is a summary of Workers’ Compensation medical services that are available to employees covered by the WellComp Network.

Primary treating and specialty services including consultations and referralsExamples of primary treating or specialty providers include: general medical practitioners, chiropractors, dentists, orthopedists, surgeons, psychologists, internists, psychiatrists, cardiologists, neurologists.

Inpatient Hospital and Outpatient Surgery Center servicesExamples of inpatient hospital and outpatient surgery center providers include: acute hospital services, general nursing care, operating room and related facilities, intensive care unit and services, diagnostic lab or x-ray services, necessary therapies.

Ancillary Care servicesExamples of ancillary care providers include: diagnostic lab or x-ray services, physical medicine, occupational therapy, medical and surgical equipment, counseling, nursing, medically appropriate home care, medication.

Emergency services including outpatient and out-of area emergency care

WellComp Provider DirectoryFor more information about the MPN including access to a roster of all treating physicians in the MPN, go to www.WellComp.com where you can search by medical specialty, zip code, physician or provider group. For website assistance or to access a hard copy of the regional area listing and/or an electronic copy of the complete WellComp directory, please contact WellComp (your employer’s designated medical provider network administrator):

WellComp InformationFor questions about the use of MPN’s or complaints The MPN contact is: Gale Chmidling,MPN Manager (800)544-8150

WellComp has individuals available to answer questions, provide website assistance, and generate provider listings. Medical Access Assistants are available to assist with finding an MPN physicians of your choice, including scheduling and confirming physician appointments. Assistants are available 7am to 8pm Pacific Standard Time, Monday through Saturday at the contact information below:

WellCompPatient Services Department

P.O. Box 59914Riverside, CA 92517

Toll Free (800) 544-8150fax: (888) 620-6921 or

e-mail: [email protected]

Employee Notification

This pamphlet contains important information on accessing the WellComp Medical Provider Network:

ü Find out if you are covered ü Access medical care ü Learn about continuity of careü Choose your own physicianü Transfer into the WellComp Networkü Contact WellComp

Rev 12/14

MPN Identification Number:

This pamphlet is available in Spanish. For a free copy, please contact WellComp Medical Provider Network.

Este folleto esta disponible en el Español. Para una copia gratis, favor de llamar a WellComp Medical Provider Network

En caso de que usted tenga una herida o la enfermedad, usted puede llevar este folleto con usted para presentar a su abastecedor de servicio médico para el acceso preocuparse.

n Cuidado InicialEn caso de emergencia usted debe llamar al 911 o ir a la sala de emergencia más cercana.En caso de que sufra una lesión o enfermedad relacionada con su trabajo, notifique inmediatamente a su supervisor y obtenga autorización médica de su empleador para designar un proveedor médico dentro de la Red, para el cuidado inicial. Si usted no puede comunicarse con su supervisor o empleador, por favor comuníquese con el Departamento del Servicio al Paciente de WellComp. Para servicios que no sean de emergencia, el MPN tendra que asegurar que usted es proveido(a) una cita o tratamiento inicial dentro de 3 dias de negocio de que su empleador o el MPN a recibido un pedido de tratamiento dentro del MPN.

n Cuidado SubsiguienteSi usted aún necesita atención después de la evaluación inicial, usted puede ser atendido por un doctor de su agrado, o el doctor inicial puede referirle a usted a un especialista médicamente y geográficamente apropiado dentro de la Red, el cual puede proveer el tratamiento adecuado para su lesión o condición. Su empleador es requerido a proveerle de por lo menos 3 medicos de cada especialidad esperada para tartar leciones experimentadas por empleados lecionados basado en su ocupacion o industria. Estos medicos estaran disponibles dentro de 30 minutos o 15 millas de su lugar de trabajo o residencia y especialistas estaran disponibles dentro de 60 minutos o 30 millas de su lugar de trabajo. Para conseguir un directorio de los proveedores médicos, por favor visite www.WellComp.com o llame al Servicio al Paciente de WellComp.

n Cuidado de EmergenciaEn una emergencia, definida como una condición médica que se manifiesta de forma imprevista, con síntomas severos, los cuales sin atención médica inmediata pueden poner en sumo riesgo su salud, vaya al proveedor de atención médica más cercano sin importar si participan en la Red de WellComp. Si su lesión está relacionada con su trabajo, pídale al proveedor del cuidado de emergencia, que se comunique con WellComp para preparar la transferencia de su atención médica, a un proveedor de WellComp cuando sea el tiempo médicamente adecuado para hacerlo.

n Cuidado Especializado y de HospitalEl proveedor principal de la Red WellComp de su tratamiento, puede hacer todos los arreglos y referencias necesarias para los especialistas, hospitales, centro de cirugía de servicio ambulatorio y servicios de cuidados auxiliares.

n Elección de Doctor para el TratamientoSi aún necesita tratamiento después de su evaluación inicial con el proveedor designado de su empleador, puede acceder al directorio WellComp y seleccione a un apropiado médico de su elección que puede proporcionar el tratamiento necesario para su condición o enfermedad. Para asistencia en obtener opciones de medicos, favor de contactar al Asistente de Acceso Medico en el Departamento de Servicios al Paciente de WellComp o discutir las opciones con el medico inicial.

n Cambiando el Doctor Principal de su TratamientoSi usted está teniendo dificultades para programar una cita con su medico inicial o posterior, favor de comunicarse con el Asistente de Acceso Médico en el Departamento de Servicios al Paciente de WellComp o con el ajustador de reclamos que maneja su caso.

n Reservación de CitasSi usted tiene problemas haciendo sus reservaciones de citas con el proveedor inicial o el proveedor subsiguiente, por favor comunicarse con el Departamento de Servicio al Paciente de WellComp.

n Obteniendo una Recomendación a un EspecialistaSiempre y cuando usted continúe necesitando cuidado médico para su lesión o enfermedad, hay varias alternativas para obtener una recomendación a un especialista:

1. Su proveedor principal en la Red de WellComp puede hacer todos los trámites necesarios para la recomendación a un especialista. Esta recomendación será echa dentro de la Red y si es necesario fuera de la Red.

2. Usted puede seleccionar un especialista adecuado usando el Directorio de WellComp.

3. Usted puede comunicarse con el Asistente de Acceso Medico de WellComp quien le puede ayudar a coordinar arreglos necesarios.

Si su proveedor de tratamiento primario hace un referido a una clase de especialista que no esta incluido dentro la red, usted puede seleccionar un especialista fuera de la red. Para servicios que no sean de emergencia, el MPN tendra que asegurar que usted es proveido(a) una cita dentro de 20 dias de negocio de que su empleador o el MPN a recibido un referido a un especialista dentro del MPN.

n Continuidad de su Cuidado¿Que pasa si estoy siendo tratado por un doctor de Wellcomp y el doctor deja a Wellcomp?Su empleador ha suscrito una póliza de “Continuidad de Cuidado” quepuede permitirle a usted continuar el tratamiento con su doctor, si su doctor no está actualmente participando en WellComp. Si usted está siendo tratado dentro de la Red WellComp por una lesión relacionada con su trabajo y su doctor deja de tener un contrato con WellComp, su doctor puede continuar tratándolo siempre y cuando su lesión o enfermedad satisface una de las siguientes condiciones

• (Aguda) Condición médica que incluye síntomas que se manifiestan de forma imprevista y que requieren pronta atención médica, y tiene duracion menos de 90 dias.

• (Seria o Crónica) Su herida o enfermedad son el que que es serio y sigue durante al menos 90 días sin la cura llena o empeora y requiere el tratamiento en curso. Se le puede permitir que siga siendo tratado por el doctor que actualmente lo esta tratando por un período de hasta un año, hasta que una transferencia de cuidado pueda ser efectuada de una manera sana y salva.

• (Terminal) Usted tiene una enfermedad incurable o condición irreversible que probablemente cause la muerte dentro de un año o menos.

• (Cirugía Pendiente) Usted ya tiene una cirugía u otro procedimiento autorizado por su empleador o seguro de salud y el cual ocurrirá dentro de los 180 días de la fecha efectiva de la Red de Proveedores Médicos (MPN por sus siglas en inglés).

Si cualquiera de las condiciones antes mencionadas existe, Wellcomp puede requerir que su doctor acepte por escrito los mismos términos que el había aceptado cuando era un proveedor del Red de Wellcomp. Si el doctor no está de acuerdo o no acepta los términos, no podría continuar tratándolo.

Si el contrato con su doctor fue clausurado o no fue renovado por Wellcomp por razones relacionadas con causas de disciplina médica, fraude o actividad criminal, no le será permitido completar el tratamiento con ese doctor. Para obtener una copia completa de la póliza de Continuidad de Cuidado en inglés o en español, por favor visite www.WellComp.com o llame a servicios al paciente de WellComp.

n Transferencia del Cuidado Actual y Corriente¿Qué pasa si usted ya está siendo tratado por una lesión relacionada con su trabajo, antes de comenzar el programa Red de WellComp?

Su empleador tiene una póliza de “Transferencia de Cuidado” que describe lo que pasará si usted esta actualmente siendo tratado por una lesión relacionada con su trabajo, por un doctor que no es miembro de la Red de WellComp. Si su doctor actual del tratamiento es un miembro participante de Wellcomp, entonces usted puede continuar el tratamiento con su doctor y su tratamiento se hará bajo la Red de Wellcomp. Se le puede permitir ser miembro de WellComp a su doctor actual. Si su médico tratante actual no es un médico participante dentro de WellComp, y si aún no ha sido transferido a la red de proveedores medicos, su médico puede hacer remisiones a prestadores dentro o fuera de la red de proveedores medicos. Se le puede permitir a su medico actual convertirse en un miembro de WellComp. Usted no será transferido a un doctor de Wellcomp si su lesión o enfermedad satisface cualquiera de las siguientes condiciones:

• (Aguda) El tratamiento de su lesión o enfermedad será completado en menos de 90 días.

• (Seria o Crónica) Su lesión o enfermedad es seria y continuará por mas de 90 días sin cura completa o empeorando y requiere tratamiento continuo. Se le puede permitir que siga siendo tratado por el doctor que actualmente lo esta tratando por un período de hasta un año de la fecha de notificacion que usted tiene una condicion seria o cronica.

• (Terminal) Usted tiene una enfermedad incurable o condición irreversible que probablemente cause la muerte dentro de un año o menos. Tratamiento medico sera proporcionado por la duracion de la enfermedad terminal.

• (Cirugía Pendiente) Usted ya tiene una cirugía o procedimiento autorizado por su empleador o seguro de salud y el cual ocurrirá dentro de los 180 días de la fecha efectiva de la Red de Proveedores Médicos (MPN por sus siglas en inglés).

• Para obtener una copia completa de la poliza de Transferencia de Cuidado en español o en ingles, por favor visite www.WellComp.com o llame a servicios al paciente de WellComp.

n Disputas de CuidadoAnuncio de la determinación, proveniente del empleador, o del ajustador encargado del caso, debera ser enviada a la dirección del empleado y una copia de la carta deberá ser enviada al medico principal del empleado cubierto. La notificación será escrita en inglés y español y los términos del lego de uso en el mayor grado posible. Si Wellcomp va a transferir su cuidado médico y usted no está de acuerdo, usted puede pedirle al doctor que lo está tratando actualmente, un informe o parte médico alegando que su condición pertenece o está dentro de una de las condiciones antes mencionadas. Su doctor que lo esta tratando actualmente si le proveera un informe dentro de veinte dias del calendario de la fecha de solicitacion. Si su doctor que lo esta tratando actualmente no logra emitir el informe, entonces usted sera requerido a selecionar un nuevo proveedor dentro el MPN.Si Wellcomp o usted no está de acuerdo con el informe del doctor que lo está tratando, esta disputa será resuelta de acuerdo a la Sección 4062 del Código del Trabajo. Usted tiene que notificar al Departamento del Servicio al Paciente de WellComp, si usted no está de acuerdo con el informe o parte médico.Si el doctor que lo está tratando está de acuerdo de que su condición no pertenece o no está dentro de las condiciones antes mencionadas, se continuará con la transferencia de su cuidado médico, aún cuando usted no está de acuerdo con la decisión.Si su doctor cree que su condición satisface una de las condiciones antes mencionadas, usted puede continuar el tratamiento con ese doctor hasta que la disputa sea resuelta. Para obtener una copia completa de la póliza de Transferencia de Cuidado, por favor visite www.Wellcomp.com o llame al Servicio al Paciente de Wellcomp.

Accesibil idad al Cuidado MédicoBienvenidos a WellCompSu empleador ha elegido proveerle a usted con una amplia selección de servicios médicos en casos de lesiones y enfermedades relacionadas con su trabajo, y para ello ha establecido una Red de Proveedores Médicos (MPN por sus siglas en inglés), llamada WellComp. WellComp suministra cuidado médico de calidad a través de su elección de un proveedor médico que esta afiliado a una red exclusiva de proveedores de asistencia sanitaria, donde cada uno posee un profundo entendimiento del sistema del Seguro de Indemnización por Accidentes de Trabajo del estado de California y el impacto que sus decisiones tienen en su persona. Su empleador ha recibido aprobación del Estado de California para cubrir sus necesidades de cuidado médico relacionadas con el Seguro de Indemnización por Accidentes de Trabajo a través de la Red WellComp. Usted está protegido automáticamente por la Red WellComp si la fecha de su lesión o enfermedad es en o después de la fecha del establecimiento de WellComp por parte de su empleador, y si usted no ha pre-designado un doctor personal antes de su lesión o enfermedad.

No se requiere que este folleto reciba servicios médicos

Proceso para Segunda Opinión, Tercera Opinión y Examen Médico Independiente:Si usted no está de acuerdo con su doctor o no le gusta su doctor sea cual sea la razón, usted siempre puede elegir otro doctor en el MPN (Red de Proveedores).

n Obteniendo Segunda y Tercera Opiniones Si usted no está de acuerdo con el diagnóstico o con el plan de tratamiento de su doctor actual o con el doctor de la segunda opinión, y quisiera una segunda o tercera opinión, usted debe de tomar los siguientes pasos:ü Notificar al Administrador(a) de su reclamo a quien le proveerá

una lista de doctores y/o especialistas en el area regional dentro de la Red de WellComp, quienes tienen pericia reconocida para evaluar o tratar su lesión o condición.

ü Elija un doctor o especialista de la lista.ü Dentro de los 60 días de recibir la lista, reserve una cita con el doctor

o especialista seleccionado de la lista proporcionada a tráves del por Administrador(a) de su reclamo. Si, dentro de los 60 días, decide usted en no confirmar cita, su derecho en buscar otra opinion puede ser renunciado.

ü Informe al Administador(a) de su reclamo de su elección, y de la fecha de su cita, para así asegurarnos de que sus archivos médicos se pueden enviar antes de la fecha de su cita. Usted tambien puede pedir una copia de sus archivos medicos.

ü Usted sera proveido(a) con informacion y un impreso de pedido referente al proceso de Examinacion de Medico Independiente (IMR) en el momento que usted selecciona un medico de tercera opinion. Informacion del proceso del IMR se puede encontrar en el Manual del MPN para el Empleado.

Si el segundo/tercer doctor de opinión siente que su herida es fuera del tipo de herida él o ella normalmente trata, el consultorio del doctor notificará a su patrón o asegurador. Usted conseguirá otra lista de doctores MPN o especialistas entonces usted puede hacer otra selección. Si la 2da/3ra opinion médico está de acuerdo con su necesidad de un tratamiento o algun examen, se le permitira obtener ese tratamiento o examen con un proveedor que este dentro o fuera de la red de proveedors medicos, incluyendo el medico quien proporciono la 2da/3ra opinion.

n Obteniendo un Examen Médico Independiente (IMR por sus siglas en inglés)Si usted no esta de acuerdo con el diagnostico o plan de tratamiento decidido por el medico de la tercera opinion, usted podria completer y presentar el impreso de la Aplicacion para Examinacion de MPN Medico Independiente con el Director Administrativo de la Division de Indemnizacion de Trabajadores. Se puede communicar con su Administrador(a) de reclamo, o al Departamento de Servicios para el Paciente de WellComp para informacion sobre la Examinacion de Medico Independiente y el impreso para pedir una Examinacion de Medico Independiente.

Si la segunda opinión, tercera opinión o la revision medica independiente, coincide con el medico que le esta tratando, y la red de proveedores medicos contiene un medico que pueda proporcionar el tratamiento recomendado, usted tendra que continuar su tratamiento con un medico dentro de la red de proveedores medicos. Si la revision medica independiente no está de acuerdo con su médico tratante de la red, se permitirá recibir ese tratamiento médico de un proveedor dentro o fuera de la red de WellComp.Cualquier médico seleccionado fuera de la red de proveedores medicos WellComp debe estar a una distancia geográfica razonable. El tratamiento o examen de diagnóstico esta limitado a la recomendación provista por el medico dentro de la red de proveedores medicos o por la revision medica independiente.

n Tratamiento Fuera del Área GeográficaWellComp tiene proveedores por todo California. Si llega alguna situacion que podria llevarlo fuera del area de cubertura, tales como trabajo temporal, viaje relacionado al trabajo, o vivir temporalmente o constantemente fuera del area de servicios geograficos del MPN, porfavor pongase en contacto con el Departamento de Servicios para Pacientes de WellComp, su examinador de reclamos, su proveedor primario de tratamiento, y ellos le proveeran con una seleccion de por lo menos 3 proveedores aprovados fuera de la red de los que usted pueda obtener tratamiento o recibir segunda o tercera opinions de la seleccion de medicos referidos.

Servicios Médicos Proveídos:A continuación es un resumen de los servicios médicos del Seguro de Indemnización por Accidentes de Trabajo disponibles para usted por la Red de WellComp.

Tratamiento principal o primario y servicios especiales incluyendo las consultaciones y recomendacionesE jemplos de proveedores de tratamientos primarios o proveedores de especialización incluyen: doctoresde medicina general, quiroprácticos, dentistas, ortopedistas, cirujanos, psicólogos, psiquiatras, cardiólogos, neurólogos.

Servicios de Hospital, y Centros de Cirugía AmbulatoriaEjemplos de servicios de proveedores de servicios de hospital, y centros de cirugía ambulatoria incluyen: servicio agudo de hospital, cuidado general de enfermera, salas de operaciones y facilidades relacionadas, unidad de cuidado intensivo y sus servicios, laboratorios para diagnósticos o servicio de rayos-x y los tratamientos de terapias necesarias.

Servicios de Cuidado ComplementariosEjemplos de proveedores de servicios de cuidado complementarios incluyen: laboratorios para diagnósticos o servicio de rayos-x, medicina física, terapia de ocupación, equipos médicos y de cirugía, consejeros, enfermeras, cuidado médico apropiado en casa, medicación.

Servicios de Emergencia incluye el servicio ambulatorio y servicio fuera del área de la Red.

Directorio de Proveedores de WellComp

Para obtener más información acerca de la red de proveedores medicos, incluyendo el acceso a una lista de todos los médicos en la red, vaya a www.WellComp.com donde se puede buscar por especialidad médica, el código postal, grupo médico o proveedor. Para asistencia atraves del internet o para optener acceso a una copia impresa de la lista de proveedores por zona regional y/o una copia electrónica del directorio completo de WellComp, favor de contactarse con WellComp (quien fue asignado por su empleador para administrar la red de proveedores medicos):

Informacion de WellCompPara preguntas sobre el uso de la red de proveedores medicos o para denuncias, la persona a contactar es: Gale Chmidling, MPN Manager (800) 544-8150.

WellComp tiene personas disponibles para responder a sus preguntas, proporcionar asistencia con el sitio web y para generar listas de proveedores. Asistentes están disponibles para ayudar a encontrar un médico de su elección dentro de la red de proveedores, incluyendo programación y confirmacion de las citas. Los asistentes están disponibles de 7am a 8pm hora del Pacífico, de lunes a sábado. Información de contacto aparece a continuacion:

WellCompDepartamento de Servicios al Paciente

P.O. Box 59914Riverside, CA 92517

Gratis al (800) 544-8150fax: (888) 620-6921 o

e-mail: [email protected]

Notificación al Empleado Este folleto contiene información importante para el acceso en la Red de Proveedores Médicos WellComp.ü Entérese si está protegidoü Acceso a cuidado médicoü Aprenda acerca de la continuidad de

su cuidadoü Seleccione su propio doctorü Transferencia dentro de la Red de

WellCompü Comunicarse con WellComp

Número de identificación del MPN:

Este folleto está disponible en Ingles. Para una copia gratis, por favor llame la Red de Proveedores Médicos de WellComp.

Rev 12/14

Rev.01.29.2019

____________________________________________________________________________

OUSD List of Participating Workers Compensation Clinics

__________________________________________________________________________________________________________________________________________

PACIFIC URGENT CARE 2115 N. Tustin St. Orange, CA 92865 Phone: (714) 921-3870 7 days a week 8am to 8pm RESTORE ORTHO & SPINE 1120 W. La Veta Ave. Ste. 300 Orange, CA 92868 Phone: (714) 598-1745 M-F 8:00am to 5:30pm SUNRISE MEDICAL CENTER 867 S. Tustin St. Orange, CA 92866 Phone: (714) 771-1420 Open 24 hours 7 days a week Please call for service after 10pm US HEALTH WORKS 800 N. Tustin Ave. Ste. A Santa Ana, CA 92705 Phone: (714) 245-0800 M-F 8:00am to 6:00pm


Appendix C

DWC 7 (1/1/2016)

STATE OF CALIFORNIA - DEPARTMENT OF INDUSTRIAL RELATIONS Division of Workers' Compensation

Notice to Employees--Injuries Caused By Work

You may be entitled to workers' compensation benefits if you are injured or become ill because of your job. Workers' compensation covers most work-related physical or mental injuries and illnesses. An injury or illness can be caused by one event (such as hurting your back in a fall) or by repeated exposures (such as hurting your wrist from doing the same motion over and over).

Benefits. Workers' compensation benefits include: Medical Care: Doctor visits, hospital services, physical therapy, lab tests, x-rays, medicines, medical equipment and travel costs that

are reasonably necessary to treat your injury. You should never see a bill. There are limits on chiropractic, physical therapy and occupational therapy visits.

Temporary Disability (TD) Benefits: Payments if you lose wages while recovering. For most injuries, TD benefits may not be paid for more than 104 weeks within five years from the date of injury.

Permanent Disability (PD) Benefits: Payments if you do not recover completely and your injury causes a permanent loss of physical or mental function that a doctor can measure.

Supplemental Job Displacement Benefit: A nontransferable voucher, if you are injured on or after 1/1/2004, your injury causes permanent disability, and your employer does not offer you regular, modified, or alternative work.

Death Benefits: Paid to your dependents if you die from a work-related injury or illness.

Naming Your Own Physician Before Injury or Illness (Predesignation). You may be able to choose the doctor who will treat you for a job injury or illness. If eligible, you must tell your employer, in writing, the name and address of your personal physician or medical group before you are injured. You must obtain their agreement to treat you for your work injury. For instructions, see the written information about workers' compensation that your employer is required to give to new employees.

If You Get Hurt: 1. Get Medical Care. If you need emergency care, call 911 for help immediately from the hospital, ambulance, fire department or

police department. If you need first aid, contact your employer.

2. Report Your Injury. Report the injury immediately to your supervisor or to an employer representative. Don't delay. There are time limits. If you wait too long, you may lose your right to benefits. Your employer is required to provide you with a claim form within one working day after learning about your injury. Within one working day after you file a claim form, your employer or claims administrator must authorize the provision of all treatment, up to ten thousand dollars, consistent with the applicable treatment guidelines, for your alleged injury until the claim is accepted or rejected.

3. See Your Primary Treating Physician (PTP). This is the doctor with overall responsibility for treating your injury or illness. If you predesignated your personal physician or a medical group, you may see your personal physician or the medical group

after you are injured. If your employer is using a medical provider network (MPN) or a health care organization (HCO), in most cases you will be

treated within the MPN or HCO unless you predesignated a personal physician or medical group. An MPN is a group of physicians and health care providers who provide treatment to workers injured on the job. You should receive information from your employer if you are covered by an HCO or a MPN. Contact your employer for more information.

If your employer is not using an MPN or HCO, in most cases the claims administrator can choose the doctor who first treats you when you are injured, unless you predesignated a personal physician or medical group.

4. Medical Provider Networks. Your employer may be using an MPN, which is a group of health care providers designated to provide treatment to workers injured on the job. If you have predesignated a personal physician or medical group prior to your work injury, then you may go there to receive treatment from your predesignated doctor. If you are treating with a non-MPN doctor for an existing injury, you may be required to change to a doctor within the MPN. For more information, see the MPN contact information below:

MPN website: ________________________________________________________________________________________________________________________

MPN Effective Date: _______________________ MPN Identification number: ___________________________________________

If you need help locating an MPN physician, call your MPN access assistant at: ___________________________________________

If you have questions about the MPN or want to file a complaint against the MPN, call the MPN Contact Person at: ______________

Discrimination. It is illegal for your employer to punish or fire you for having a work injury or illness, for filing a claim, or testifying in another person's workers' compensation case. If proven, you may receive lost wages, job reinstatement, increased benefits, and costs and expenses up to limits set by the state.

Questions? Learn more about workers' compensation by reading the information that your employer is required to give you at time of hire. If you have questions, see your employer or the claims administrator (who handles workers' compensation claims for your employer):

Claims Administrator____________________________________________________ Phone ________________________________

Workers’ compensation insurer (Enter “self-insured” if appropriate)

You can also get free information from a State Division of Workers' Compensation Information (DWC) & Assistance Officer. The nearest Information & Assistance Officer can be found at location: or by calling toll-free (800) 736-7401. Learn more information about workers’ compensation online: www.dwc.ca.gov and access a useful booklet “Workers’ Compensation in California: A Guidebook for Injured Workers.”

False claims and false denials. Any person who makes or causes to be made any knowingly false or fraudulent material statement or material representation for the purpose of obtaining or denying workers' compensation benefits or payments is guilty of a felony and may be fined and imprisoned.

Your employer may not be liable for the payment of workers' compensation benefits for any injury that arises from your voluntary participation in any off-duty, recreational, social, or athletic activity that is not part of your work-related duties.

DWC 7 (1/1/2016)

ESTADO DE CALIFORNIA - DEPARTAMENTO DE RELACIONES INDUSTRIALES División de Compensación de Trabajadores

Aviso a los Empleados—Lesiones Causadas por el Trabajo Es posible que usted tenga derecho a beneficios de compensación de trabajadores si usted se lesiona o se enferma a causa de su trabajo. La compensación de trabajadores cubre la mayoría de las lesiones y enfermedades físicas o mentales relacionadas con el trabajo. Una lesión o enfermedad puede ser causada por un evento (como por ejemplo lastimarse la espalda en una caída) o por acciones repetidas (como por ejemplo lastimarse la muñeca por hacer el mismo movimiento una y otra vez). Beneficios. Los beneficios de compensación de trabajadores incluyen:

• Atención Médica: Consultas médicas, servicios de hospital, terapia física, análisis de laboratorio, radiografías, medicinas, equipo médico y costos de viajar que son razonablemente necesarias para tratar su lesión. Usted nunca deberá ver un cobro. Hay límites para visitas quiroprácticas, de terapia física y de terapia ocupacional.

• Beneficios por Incapacidad Temporal (TD): Pagos si usted pierde sueldo mientras se recupera. Para la mayoría de las lesiones, beneficios de TD no se pagarán por más de 104 semanas dentro de cinco años después de la fecha de la lesión.

• Beneficios por Incapacidad Permanente (PD): Pagos si usted no se recupera completamente y si su lesión le causa una pérdida permanente de su función física o mental que un médico puede medir.

• Beneficio Suplementario por Desplazamiento de Trabajo: Un vale no-transferible si su lesión surge en o después del 1/1/04, y su lesión le ocasiona una incapacidad permanente, y su empleador no le ofrece a usted un trabajo regular, modificado, o alternativo.

• Beneficios por Muerte: Pagados a sus dependientes si usted muere a causa de una lesión o enfermedad relacionada con el trabajo.

Designación de su Propio Médico Antes de una Lesión o Enfermedad (Designación previa). Es posible que usted pueda elegir al médico que le atenderá en una lesión o enfermedad relacionada con el trabajo. Si elegible, usted debe informarle al empleador, por escrito, el nombre y la dirección de su médico personal o grupo médico, antes de que usted se lesione. Usted debe de ponerse de acuerdo con su médico para que atienda la lesión causada por el trabajo. Para instrucciones, vea la información escrita sobre la compensación de trabajadores que se le exige a su empleador darle a los empleados nuevos. Si Usted se Lastima: 1. Obtenga Atención Médica. Si usted necesita atención de emergencia, llame al 911 para ayuda inmediata de un hospital, una

ambulancia, el departamento de bomberos o departamento de policía. Si usted necesita primeros auxilios, comuníquese con su empleador.

2. Reporte su Lesión. Reporte la lesión inmediatamente a su supervisor(a) o a un representante del empleador. No se demore. Hay límites de tiempo. Si usted espera demasiado, es posible que usted pierda su derecho a beneficios. Su empleador está obligado a proporcionarle un formulario de reclamo dentro de un día laboral después de saber de su lesión. Dentro de un día después de que usted presente un formulario de reclamo, el empleador o administrador de reclamos debe autorizar todo tratamiento médico, hasta diez mil dólares, de acuerdo con las pautas de tratamiento aplicables a su presunta lesión, hasta que el reclamo sea aceptado o rechazado.

3. Consulte al Médico que le está Atendiendo (PTP). Este es el médico con la responsabilidad total de tratar su lesión o enfermedad. Si usted designó previamente a su médico personal o grupo médico, usted puede consultar a su médico personal o grupo

médico después de lesionarse. Si su empleador está utilizando una Red de Proveedores Médicos (MPN) o una Organización de Cuidado Médico (HCO),

en la mayoría de los casos usted será tratado dentro de la MPN o la HCO a menos que usted designó previamente un médico personal o grupo médico. Una MPN es un grupo de médicos y proveedores de atención médica que proporcionan tratamiento a trabajadores lesionados en el trabajo. Usted debe recibir información de su empleador si está cubierto por una HCO o una MPN. Hable con su empleador para más información.

Si su empleador no está utilizando una MPN o HCO, en la mayoría de los casos el administrador de reclamos puede escoger el médico que lo atiende primero, cuando usted se lesiona, a menos que usted designó previamente a un médico personal o grupo médico.

4. Red de Proveedores Médicos (MPN): Es posible que su empleador use una MPN, lo cual es un grupo de proveedores de asistencia médica designados para dar tratamiento a los trabajadores lesionados en el trabajo. Si usted ha hecho una designación previa de un médico personal antes de lesionarse en el trabajo, entonces usted puede recibir tratamiento de su médico previamente designado. Si usted está recibiendo tratamiento de parte de un médico que no pertenece a la MPN para una lesión existente, puede requerirse que usted se cambie a un médico dentro de la MPN. Para más información, vea la siguiente información de contacto de la MPN :

Página web de la MPN: _______________________________________________________________________________________________ Fecha de vigencia de la MPN: ___________________ Número de identificación de la MPN: _______________________________________ Si usted necesita ayuda en localizar un médico de una MPN, llame a su asistente de acceso de la MPN al: __________________________ Si usted tiene preguntas sobre la MPN o quiere presentar una queja en contra de la MPN, llame a la Persona de Contacto de la MPN al: _______________________________________________________________________________________________________

Discriminación. Es ilegal que su empleador le castigue o despida por sufrir una lesión o enfermedad en el trabajo, por presentar un reclamo o por testificar en el caso de compensación de trabajadores de otra persona. De ser probado, usted puede recibir pagos por pérdida de sueldos, reposición del trabajo, aumento de beneficios y gastos hasta los límites establecidos por el estado.

¿Preguntas? Aprenda más sobre la compensación de trabajadores leyendo la información que se requiere que su empleador le dé cuando es contratado. Si usted tiene preguntas, vea a su empleador o al administrador de reclamos (que se encarga de los reclamos de compensación de trabajadores de su empleador):

Administrador de Reclamos _____________________________________________ Teléfono _______________________________

Asegurador del Seguro de Compensación de trabajador _______________________________ (Anote “autoasegurado” si es apropiado)

Usted también puede obtener información gratuita de un Oficial de Información y Asistencia de la División Estatal de Compensación de Trabajadores. El Oficial de Información y Asistencia más cercano se localiza en: ________________________________________ o llamando al número gratuito (800) 736-7401. Usted puede obtener más información sobre la compensación del trabajador en el Internet en: www.dwc.ca.gov y acceder a una guía útil “Compensación del Trabajador de California Una Guía para Trabajadores Lesionados.”

Los reclamos falsos y rechazos falsos del reclamo. Cualquier persona que haga o que ocasione que se haga una declaración o una representación material intencionalmente falsa o fraudulenta, con el fin de obtener o negar beneficios o pagos de compensación de trabajadores, es culpable de un delito grave y puede ser multado y encarcelado.

Es posible que su empleador no sea responsable por el pago de beneficios de compensación de trabajadores para ninguna lesión que proviene de su participación voluntaria en cualquier actividad fuera del trabajo, recreativa, social, o atlética que no sea parte de sus deberes

laborales.

Documents

Orange Unified School District Injury and Illness Prevention ......Injury and Illness Prevention S.Solis Orange Unified School District Injury and Illness Prevention Program (IIPP)