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213360-38354000 Reporting an Accident/InjuryAccident/Injury OccursEmployee Reports Accident/Injury to Supervisor/HR If Accident/Injury is life threatening, Supervisor calls 911 or sends employee to the nearest hospital.If Accident/Injury requires immediate medical attention (not life threatening) and request medical treatment, Supervisor sends employee to the applicable urgent care clinic below. If employee is sent for medical treatment, Supervisor supplies employee with the Introductory Letter to PhysicianIf employee declines medical treatment, supervisor makes sure that this is indicated on the paperwork.Supervisor Collects the following paperwork and sends to HRFirst Report of Injury – Completed by Supervisor/EmployeeSupervisor’s Report of Injury – Completed by Supervisor Employee’s Report of Injury – Completed by EmployeeProvide any witness statementsHR files claim with Worker’s Compensation Insurance Carrier.W/C Insurance company will continue to stay in touch with HR and Injured EmployeeOffice/Store 83, 134, 347, & 371 (Cocoa/M.I.)Medfast Urgent Care Centers LLC5005 Port St John PkwyCocoa, FL 32927(321) 633-8620Store 127 (Waldo)CareSpot Express Healthcare720 SW 2nd Ave Ste 160AGainesville, FL 32601(352) 240-8000Store 12 (Yeehaw Junction)Urgent Care West2050 40th Ave Ste 6Vero Beach, FL 32960(772) 564-0175Best Western Hotel & Store 24 (Titusville)Medfast Urgent Care Centers LLC5005 Port St John PkwyCocoa, FL 32927(321) 633-8620Store 242 (Scottsboro, AL)Highlands Occupational Medicine Center102 Micah Way Ste 1107Scottsboro, AL 35769(256) 218-3860Store 50 and 52DQ (Fellsmere)Indian River Health Services Inc801 Wellness Way Ste 107Sebastian, FL 32958(772) 226-4200Store 172 and 357 (Palm Bay)Medfast Urgent Care Centers LLC490 Centre Lake Dr NE Ste 200APalm Bay, FL 32907(321)821-4950Store 91DQ (Saint Augustine)Healing Arts Urgent Care120 Health Park Blvd Ste 1Saint Augustine, FL 32086(904) 823-3401Store 130 (Jacksonville)CareSpot Express Healthcare2032 Dunn AveJacksonville, FL 32218(904) 757-2008Store 175 (Melbourne)Medfast Urgent Care Centers LLC7925 N Wickham Rd Ste AMelbourne, FL 32940(321) 751-7222Store 178 (Altamonte Springs)Florida Hospital Central Care440 W Hwy 436Altamonte Springs, FL 32714(407) 788-2000Store 204 (Ormond Beach)Prime Care at Twin Lakes LLC1890 LPGA Blvd Ste 130Daytona Beach, FL 32117(386) 274-2212Store 296 (Davenport)Legends Family Medical Center1485 Legends BlvdChampions Gate, FL 33896(407) 390-6480Store 302 (Winter Park)Florida Hospital Central Care3099 Aloma AveWinter Park, FL 32792(407) 677-0961Store 306 and 345 (Sanford)Florida Hospital Central Care4451 W. State Road 46Sanford, FL 32771(407) 330-3412Store 350 (Orlando)Florida Hospital Central Care12500 S Apopka Vineland RdOrlando, FL 32821(407) 934-2273Store 392 (Fernandina Beach)Amelia Urgent Care LLC96279 Brady Point RdFernandina Beach, FL 32034(904) 321-0088Store 401 (Winter Haven)First Help Urgent Care Clinic320 1st St SWinter Haven, FL 33880(863) 299-8485-7620-54356000First Report of Accident/InjuryInjured Employee’s Name FORMTEXT ?????Location FORMTEXT ?????Position Title FORMTEXT ?????Social Security Number FORMTEXT ?????Date of Birth FORMTEXT ?????Gender FORMCHECKBOX Male FORMCHECKBOX FemaleEmployee Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip FORMTEXT ?????Hire Date FORMTEXT ?????Manager/Supervisor FORMTEXT ?????Rate of Pay FORMTEXT ????? FORMCHECKBOX hr FORMCHECKBOX wkNumber of hours work per day FORMTEXT ?????Number of days work per week FORMTEXT ?????Date of Accident / Illness FORMTEXT ?????Time of Injury FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmDate Reported FORMTEXT ?????*Any witnesses? FORMCHECKBOX Yes FORMCHECKBOX NoIf witnesses, who? FORMTEXT ?????Description of the Injury or Illness FORMTEXT ?????Description of the Activity at the Time of the Accident FORMTEXT ?????Accident Resulted In: FORMCHECKBOX Injury FORMCHECKBOX Illness FORMCHECKBOX Property Damage FORMCHECKBOX Near Miss FORMCHECKBOX First Aid FORMCHECKBOX Medical Clinic Treatment FORMCHECKBOX Lost Time FORMCHECKBOX No Injury/IllnessRecommended Corrective Action FORMTEXT ?????Immediate Corrective Action Taken FORMTEXT ?????121920-39624000Supervisor's Report of Accident/InjuryEmployerM&R Enterprises of BrevardInjury Date FORMTEXT ?????Injury Time FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmInjured Employee’s Name FORMTEXT ?????Location of Accident FORMTEXT ?????Shift Start Time FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmEmployee’s Date of Birth FORMTEXT ?????Employee’s Job Title FORMTEXT ?????Nature of Injury (Scratch, cut, bruise, etc.) FORMTEXT ?????Part of Body Injured (Left Ring Finger, Right Ankle, etc.) FORMTEXT ?????Employee was Referred to: FORMTEXT ?????Did Employee Return to Work? FORMCHECKBOX Yes FORMCHECKBOX NoDate Returned to Work: FORMTEXT ?????Time Returned to Work: FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmWhere and how did the accident happen? FORMTEXT ?????Specify equipment, substance or object connected with accident? FORMTEXT ?????What was the employee doing at the time of the accident? FORMTEXT ?????Were there any witnesses? (See attached witness statements) FORMCHECKBOX Yes FORMCHECKBOX No; If yes, Names: FORMTEXT ?????Measures recommended to prevent a similar accident: FORMTEXT ?????Supervisor/Manager Name: FORMTEXT ?????Supervisor/Manager Signature:Date:83820-31242000Employee's Report of Accident/InjuryEmployerM&R Enterprises of BrevardInjury Date FORMTEXT ?????Injury Time FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmInjured Employee’s Name FORMTEXT ?????Location of Accident FORMTEXT ?????Shift Start Time FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmDate of Birth FORMTEXT ?????Requesting Medical Treatment? FORMCHECKBOX Yes FORMCHECKBOX NoJob Title FORMTEXT ?????Nature of Injury (Scratch, cut, bruise, etc.) FORMTEXT ?????Part of Body Injured (Left Ring Finger, Right Ankle, etc.) FORMTEXT ?????Employee was Referred to:? FORMTEXT ?????Did you return to work? FORMCHECKBOX Yes FORMCHECKBOX NoDate Returned to Work: FORMTEXT ?????Time Returned to Work: FORMTEXT ????? FORMCHECKBOX am FORMCHECKBOX pmWhere and how did the accident happen? FORMTEXT ?????Specify equipment, substance or object connected with accident? FORMTEXT ?????What were you doing at the time of the accident? FORMTEXT ?????Were there any witnesses? (See attached witness statements) FORMCHECKBOX Yes FORMCHECKBOX No; If yes, Names: FORMTEXT ?????Measures recommended to prevent a similar accident: FORMTEXT ?????Employee Signature:Date:45720-46482000Introductory Letter to PhysicianAmeriSys/Coventry NetworkDate: FORMTEXT ?????Employer Name: M&R Enterprises of Brevard, Inc.Employer Telephone Number: (321) 631-0245, extension 116Dear Dr. FORMTEXT ?????: FORMTEXT Employee Name is scheduled for an initial visit as an employee of M&R Enterprises of Brevard, Inc. which is a participant in the FHM Insurance Company/AmeriSys/Coventry Network. This letter does not confirm that the injury or condition is covered by Worker’s Compensation Insurance. That determination will be made as soon as an investigation is completed by our claims administrator, USIS.DRUG TESTING IS REQUIRED: FORMCHECKBOX Urinalysis FORMCHECKBOX Breathalyzer (blood test if necessary)We are working closely with AmeriSys/Coventry Network and the involved medical providers to ensure that our employees receive access to timely and medically necessary treatment for their industrial injuries. In the best interest of our employees, we will have modified work available, which would allow the employee to return to work at the earliest possible date. Please keep this in mind as you treat this employee.PLEASE CONACT UTILIZATION MANAGEMENTAT 888-346-3461 Ext. 3131WHEN ONE OF THE FOLLOWING OCCURS:New Injury with Disability > 7 Days & No Release to Return to WorkHospitalizationAnticipated SurgeryPhysical Therapy or Chiropractic Treatment RecommendedReferral to ProviderAssistance Required to Return Injured Employee to WorkRepeat Major Diagnostic StudiesAll claims for treatment must be submitted to the address below on an HCFA 1500, UB 92 or the appropriate form required by the state. Please submit all medical reports within the time frame required by the applicable state law.FHM Insurance CompanyP.O. Box 616648, Orlando, FL 32861-6648407-351-1212/888-346-3461- Ext 6353; FAX: 407-352-5788Should you have any questions regarding your participation in the Coventry Network, please call 800-342-5888 or 800-937-6824.399669012890500Sincerely,Chrissy Council, HR Manager ................
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