Employee Injury / Accident Treatment Instructions
If you are injured at work and require off premises medical assistance:
- Report the injury/accident to your supervisor or member of management as soon as possible.
- Post injury drug testing will apply to all employees seeking treatment for work related injuries requiring off premises medical treatment.
- If medical treatment is required and/or requested, your supervisor or member of management will direct you to a company authorized physician for treatment.
- Treatment by unauthorized medical facilities may not be paid for by workers’ compensation.
- Your supervisor or member of management will provide you with a Permission to Treat form. Present this form to the company authorized physician to be completed.
- When initial treatment is completed, the Permission to Treat form must be returned to the injured employee’s supervisor or other member of management.
- Modified duty may be provided if authorized by the treating physician.
- Failure to report to modified duty or regular duty if given a full release may result in the termination of workers’ compensation benefits.
- At the present time our Company Authorized Physician is:
Name: ______
Address: ______
Phone #: ______
I, ______have read the above rules, or have had them read to me. I understand the steps to be taken in the event I am injured at work. As a condition of employment, I will observe these rules in the event I am inured on the job. I understand that not following these rules may result in the loss of workers’ compensation benefits and/or possible disciplinary action up to and including termination.
Permission to Treat
Employee InformationName:______/ Date of Injury: ______
Occupation: ______/ Supervisor: ______
Nature of Injury: ______
______
Employer Information
Name: / ______
Phone Number: / ______
Address: / ______
______
______
Physician’s Report to Employer
Date Treated: ______/ Date of Injury: ______
1. / Diagnosis and possible cause:______
______
______
2. / Is injury related to employment? Yes ( ) No ( ) Doubtful ( )
3. / Can injured employee return to work at:
Full Duty status? Yes ( ) No ( ) If no then when? ______
Modified duty status? Yes ( ) No ( ) If no then when? ______
4. / What are your recommendations for treatment? ______
______
5. / Please specify any recommendations or limitations in regards to his/her work: ______
______
6. / Do you expect follow –up treatment? Yes ( ) No ( ) If yes, then when and how long? ______
______
Attending Physician: ______Date: ______
The need for the information in the attending physician’s report is authorized by our employee and your advice will be considered strictly confidential.
Please release the information referenced above:
Employee: ______Date: ______
Note to Physician: the injured employee is responsible for returning this form to his/her supervisor