Employee Injury / Accident Treatment Instructions

If you are injured at work and require off premises medical assistance:

  1. Report the injury/accident to your supervisor or member of management as soon as possible.
  1. Post injury drug testing will apply to all employees seeking treatment for work related injuries requiring off premises medical treatment.
  1. If medical treatment is required and/or requested, your supervisor or member of management will direct you to a company authorized physician for treatment.
  1. Treatment by unauthorized medical facilities may not be paid for by workers’ compensation.
  1. 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.
  1. When initial treatment is completed, the Permission to Treat form must be returned to the injured employee’s supervisor or other member of management.
  1. Modified duty may be provided if authorized by the treating physician.
  1. Failure to report to modified duty or regular duty if given a full release may result in the termination of workers’ compensation benefits.
  1. 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 Information
Name:______/ 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