Fortress.wa.gov
STATE OF WASHINGTON
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Aging and Long-Term Support Administration
Home and Community Services Division
PO Box 45600, Olympia, WA 98504-5600
H13- 059 – Procedure
August 27, 2013
|TO: |Home and Community Services (HCS) Division Regional Administrators |
| |Area Agency on Aging (AAA) Directors |
| |Developmental Disabilities Administration (DDA) Regional Administrators |
|FROM: |Bea Rector, Director, Home and Community Services Division |
| |Don Clintsman, Deputy Assistant Secretary, Developmental Disabilities Administration |
|SUBJECT: |Procedure for IPs to Fill Out a Workers’ Compensation Claim |
|Purpose: |To inform field staff of clarified procedures that Individual Providers (IPs) should follow when filing a |
| |workers’ compensation claim. |
|Background: |On October 1, 2004, IPs became eligible for workers’ compensation insurance. The Collective Bargaining |
| |Agreement (CBA) between the State of Washington and Service Employees International Union (SEIU) Healthcare |
| |775 Northwest requires the state to provide workers’ compensation insurance to all IPs. The Department of |
| |Social and Health Services (DSHS) contracts with Sedgwick CMS to provide third party administration of all IP|
| |workers’ compensation claims submitted to the Washington State Department of Labor and Industries (L&I) for |
| |coverage of any work-related illness or injury. |
|What’s new, changed, or |To receive timely benefits for injuries sustained while providing services to their employer (client), IPs |
|Clarified |must have their claim filed with L&I when their medical provider first sees them for the workplace-related |
| |injury. To help ensure that their claim is administered accurately and quickly, IPs must: |
| | |
| |Report their injury to their employer as soon as possible. Their employer needs to know about the condition |
| |of the injury and what caused it. |
| |If immediate medical attention is necessary, go to the nearest medical facility or their primary care doctor,|
| |and: |
| | |
| |Tell the doctor the injury or illness is work-related; |
| |Fill out a “Report of Accident” form (F242-130-000). A pre-assigned claim number is located at the top of |
| |the form. List the employer as State of Washington Negotiated Contract, 601 Union Street, Suite 3500, |
| |Seattle, WA 98101. Note: Do not fill out the Self-Insurer Accident Report form (SIF-2). |
| |Report their injury to Sedgwick CMS by calling 1-866-897-0386. |
| |Stay in contact with their health care provider. |
| |Work closely with their claims manager. |
| | |
| | |
|ACTION: |Effective immediately, staff must include updated instructions in all new IP packets. Instructions will be |
| |sent to current IPs with their August warrant. |
|Related | |
|REFERENCES: |For more information review the section on “What to Do if You Are Injured at Work,” found in the Workers’ |
| |Compensation Benefits: A Guide for Injured Workers,” booklet at: |
| |. |
|ATTACHMENT(S): |L&I Report of Accident Form and Instructions: |
| |[pic] |
| |Procedures for Filing and Workers’ Compensation Claim: |
| |[pic] |
| |2013-2015 Collective Bargaining Agreement: |
| |[pic] |
|CONTACT(S): |Vicki Payne, Program Manager, HCS – Home Care Referral Registry (360) 725-2573 |
| |vicki.payne@dshs. |
| | |
| |Grace Kiboneka, Program Manager, ALTSA - Planning & Development |
| |(360) 725-2598 |
| |Kibongs@dshs.. |
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