Hazleton Area School District - Hazleton Area High School

Hazleton Area School District

1515 West 23rd Street

Hazle Township, PA 18202

Memorandum

TO:

ALL STAFF

FROM:

JESSE BARRETT, PERSONNEL BENEFITS SUPERVISOR

RE:

WC FORMS

There are five (5) forms that must be completed every time you have a work

related injury. If you have any questions, please do not hesitate to contact me,

Jesse Barrett at 570-459-3111 extension 3108 or barrettj@.

_____SDIC Workers¡¯ Compensation Medical Information Release and

Employment Record Release (required even if not going to seek treatment

with a panel physician)

_____Hazleton Area School District-What to do in Case of a work-related injury

_____Workers¡¯ Compensation Report Employee/Supervisor/Witness (please have

your supervisor and any witnesses sign this before returning)

_____Employee¡¯s Rights and Duties under Section 306 (F.1) of the Pennsylvania

Workers¡¯ Compensation Act

_____Workers¡¯ Compensation Information

U:\wc\2013\REQUIRE DOCUMENTS FOR WC PACKET.doc

HAZLETON AREA SCHOOL DISTRICT

WHAT TO DO IN CASE OF A WORK-RELATED INJURY

EFFECTIVE JUNE 30, 2014 THROUGH JULY 1, 2015

If you suffer a work-related injury, your health and well being are our first concern. If the injury is of a serious nature and requires the

assistance of an ambulance or rescue personnel, they should be contacted immediately. If the injury is of a less serious nature, the

following procedures must be followed:

1.

If you suffer a work-related injury, the first thing you MUST do is report the injury to your supervisor. S/he or a designated

person in your building, will provide you with an SDIC packet, you can call ¡°First Step¡± @ 1 (800) 445-6965 ext. 101. You

must also call Jessica Barrett, Benefit Supervisor @ (570) 459-3111 ext. 3108.

2.

If you require a prescription for your work-related injury or disease, do not use your personal health plan prescription card.

Please use the JordanReses First Fill Sheet which you will receive in the claim package. When you call in your report of

injury to SDIC, they will assign you a claim number. Please use this claim number when seeing a panel physician.

3.

If you suffer a work-related injury, HAZLETON AREA SCHOOL DISTRICT or our insurer will pay reasonable surgical

and medical services and supplies, orthopedic appliances and prosthetics, including training in their use when needed. In

order to insure that your medical treatment will be paid for by Hazleton Area School District or our insurer, you must

select from one of the health-care providers listed below for your initial care:

Health & Wellness Center at Hazleton - Occupational Health

50 Moisey Drive, Suite 208

Hazleton, PA 18202

(570) 501-6800

Area of Specialty: Occupational Medicine

Hazleton Urgent Care Center

101 South Church Street

Hazleton, PA 18201

(570) 501-1017

Area of Specialty: Urgent Care

MedExpress

276 West Side Mall

Edwardsville, PA 18704

(570) 283-0791

Area of Specialty: Occupational Medicine

Modern Therapeutics

1109 West 15th Street

Hazleton, PA 18201

(570) 453-0252

Area of Specialty: Physical/Occupational Therapy

Concentra Medical Center

268 Highland Park Boulevard

Wilkes-Barre, PA 18702

(570) 822-8831

Area of Specialty: Urgent Care/Occupational Medicine

NovaCare Rehabilitation

For the nearest facility contact:

1 (866) 723-NOVA (central scheduling)

Area of Specialty: Physical Therapy

Coordinated Health

1097B North Church Street

Hazle Township, PA 18202

(877) 247-8080 ext. 34002

Area of Specialty: Orthopedics/Physiatrist

Nork Chiropractic Associates

Leonard Nork, DC

930 West 21st Street

Hazleton, PA 18202

(570) 455-0144

Area of Specialty: Chiropractor

Fyzical Therapy and Balance Centers

1324 North Church Street, Suite 4

Hazle Township, PA 18202

(570) 501-1808

Area of Specialty: Physical Therapy

Griguoli Chiropractic and Rehab Center PC

1109 West 15th Street

Hazleton, PA 18201

(570) 455-4811

Area of Specialty: Chiropractic

Anthony D¡¯Angelo, Jr., DMD

8 West Broad Street, Suite 406

Hazleton, PA 18201

(570) 454-3820

Area of Specialty: Dentist

Eye Care Specialists

1720 East Broad Street

Hazleton, PA 18201

(570) 455-3391

Area of Specialty: Ophthalmology

Degenhart Chiropractic Health Center

1749 East Broad Street

Hazleton, PA 18201

(570) 454-2474

Area of Specialty: Chiropractic

One Call Care Management

Hazleton Imaging Center

101 South Church Street

Hazleton, PA 18201

For the nearest facility contact:

1 (800) 453-0574 (central scheduling)

Area of Specialty: MRI/EMG/X-Ray/CT scan

Eyerly Chiropractic Offices

Terrance Eyerly, DC

Tricia Eyerly, DC, FACO

110 Butler Drive

Hazleton, PA 18201

(570) 455-5822

-or642 Rt. 93

Brookhill Square S, Suite 3

Conyngham, PA 18219

(570) 788-3981

Area of Specialty: Chiropractor

For Prescriptions: Please use your JordanReses card at

your local pharmacy to bill SDIC directly (Giant, CVS,

Rite Aid, Wal-Mart, Walgreens, Acme)

For Durable Medical Equipment:

MSC Equipment & Device Management

1 (800) 848-1989

Equipment: wheelchairs, walkers, crutches,

TENs units, orthotics & prosthetics, etc.

4.

Please call in advance for an appointment if you need treatment. You must continue to treat with one of these providers for

ninety (90 days) from the date of your first visit.

5.

If, after this ninety (90) day period, you still need treatment and the Hazleton Area School District has provided this list as

set forth above, you may choose to continue with this health care provider, or you may choose another provider. You must

notify Jessica Barrett, Benefit Supervisor of this action within five (5) days of your first visit to the health care provider of

your choice. Your bills will be paid if you have provided proper notice and if your provider files reports as required. (These

reports must be filed within ten (10) days after your first visit and at least once a month for as long as treatment continues.)

6.

If one of the health care providers listed above refers you to a specialist, the Hazleton Area School District or our insurer

will pay for these services as provided by law.

All workers¡¯ compensation claims will be processed on behalf of the School District by:

SCHOOL DISTRICTS INSURANCE CONSORTIUM

P.O. BOX 1249

NORTH WALES, PA 19454

Phone: (800) 445-6965

ACKNOWLEDGMENT: I have been informed of and understand my rights and duties as specified herein.

Signature: ___________________________________________________ Date: __________________________

Please Print Name: _____________________________________________________________________________

* At time of distribution, this information is accurate to the best of our knowledge. This panel is subject to change based on

information received from the medical provider.

Instructions for Claims Reporting

Please read the entire contents of the packet and follow directions below.

1.

2.

Call 1-800-445-6965 to report your work-related claim as soon as possible.

3.

You must seek medical treatment for your claimed injury with one of the providers listed

on your POSTED PANEL for ninety (90) days from the date of your first visit.

4.

Please use the enclosed Pharmacy Sheet to fill your prescription at your local Walgreen¡¯s,

CVS Pharmacy, Rite Aid, Wal-Mart or Eckerd. The Jordan Reses Company, our pharmacy

management company, will send you a personalized pharmacy card for future

prescriptions.

5.

Please notify your Claims Representative at SDIC and your Workers¡¯ Compensation

Coordinator immediately when you receive a return to work date.

Advise your Workers¡¯ Compensation Coordinator that you have reported your workrelated claim.

Please call 1-800-445-6965 if you need any assistance or have questions regarding your workrelated injury.

PLEASE MAIL MEDICAL BILLS TO:

SDIC

P.O. BOX 1249

NORTH WALES, PA 19454

WORKERS' COMPENSATION REPORT

EMPLOYEE/SUPERVISOR/WITNESS

Note to Employee: All areas of this report must be completed. Otherwise, it will be returned to you and delay the processing

of your claim.

If you are unable to return to work because of your injury, you MUST contact the Business Office by the following business day.

Failure to do so could jeopardize your claim.

Name

Soc. Sec. #

Date of Accident

Date of Hire

Date of Birth

Address:

Number

Street

Apt. #

Phone Number (include area code)

City

State

Zip Code

Accident Reported to:

Title:

Building where injured:

Other Employer(s):

Address:

School District:

Contact: ____________________

Position:

Describe Accident/Injury:

Have you returned to work? (Circle one)

YES

NO

List prior injuries or conditions:

Date of first treatment: _____________________________

Are you still under treatment? (Circle one)

YES

If YES, when?

NO

Medical treatment was received from: __________________

Employee Signature: ___________________________________

Date: ________________________

WITNESS' REPORT

Witness' Name: (Please Print) __________________________________________________________

To the best of my knowledge, this accident occurred as reported by the claimant. (Circle one)

YES

NO

If you are unable to confirm the claimant's version of the accident, please explain why: __________________________

________________________________________________________________________________________

Witness' Signature: ________________________________________

Date: _____________________

SUPERVISOR'S REPORT

Supervisor's Name: (Please print) __________________________________________________________________

This employee reported the above incident to me on: ________________________________________

To the best of my knowledge, this accident occurred as reported by the claimant. (Circle one)

YES

NO

If you are unable to confirm the claimant's version of the accident, please explain why: __________________________

________________________________________________________________________________________

List recommendations to prevent recurrence:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Supervisor's Signature: ________________________________________

Date: _____________________

Employee/Supervisor/Witness 6/22/07

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