IF AN INJURY OCCURS AT WORK, YOU MUST

IF AN INJURY OCCURS AT WORK, YOU MUST:

A. Report the accident immediately to your supervisor.

B. A physician chosen from the PANEL OF PHYSICIANS must be used if

medical treatment is needed.

C. If a panel physician is unavailable at the time of an emergency, an

emergency facility may treat you; however, any follow up care must be

rendered by the physician chosen by you from the Panel of Physicians.

D. Your Panel Physician can refer you to a specialist if needed. You may not

choose a specialist yourself.

E. As Virginia Law requires, (Section 65.2-603), enclosed is a Panel of

Physicians from which you must chose one as your treating physician. If

you do not receive treatment from a Panel Physician, your Workers'

Compensation benefits may be terminated and your medical bills will not

be paid. If you sustain a compensable work injury, your Workers'

Compensation Administrator will only be responsible for bills from the

following:

1. Panel Physicians

2. Authorized treating specialist

3. An emergency facility in a true emergency

v

1

STEP4 VRSA CompCare On-Call immediately notifies the medical facility if the injuredemployee is seeking treatment.CompCare On-Call inmediatamente notifica al centro médico si el empleado lesionado está por llegar y envia informes de incidente al empleador.amente al 9-1-1.

IMPORTANT: If the employee is unable or unwilling to call CompCare On-Call, the supervisor must call to report the injury.

IMPORTANTE: Por favor llame a CompCare On-Call ante de procurar tratamiento para emergencias ue no constituyan una amenaza a la vida y antes de abandonar el lugar de trabajo cuando sea posible.

www.vrsa.us | 800-963-6800

In the event of a Workplace Injury

En Caso De Una Lesión En ElLugar De Trabajo

STEPInjured employee immediately notifies supervisor of incident.Empleado lesionado notifica a su supervisor del incidente.

If this is a life or limb threatening injury, immediately dial 9-1-1.Si se trata de una lesion que amenaza la vida o una extremidad, llame inmediatamente al 9-1-1.

2STEPInjured employee immediately calls CompCare On-Call.Supervisor & empleado lesionado llamen inmediatamente a CompCare On-Call.

1-877-234-0898

STEP3 VRSA CompCare On-Call gathers pertinent information and advises the injuredemployee on appropriate care.CompCare On-Call recopila información pertinente y guia al empleado lesionado a atención adecuada.

Call 24-HoursLlame las 24-Horas

1-877-234-0898

CompCare On-Call Virginia Risk Sharing Association (VRSA) has partnered with S1 Medical to offer CompCare On-Call workers’

compensation nurse triage and reporting services.

All VRSA members have been enrolled for this service and are encouraged to participate in CompCare On-

Call, regardless of the number of workers’ compensation claims that are reported each year. The

assistance provided by an employer immediately following a work-related incident greatly determines the

outcome of a workers’ compensation claim (time lost from work, cost, etc.). With CompCare On-Call

employees have the opportunity to speak with a registered nurse (RN), immediately following the work-

related incident. The RN provides triage services and provides advice to the employee for appropriate

care.

The RN will also collect the information necessary to complete the state required Employer’s Accident

Report. Following the call with CompCare On-Call, an accident report will be sent to the member and

VRSA. If these services are utilized, the supervisor / member no longer needs to complete an Employer’s

Report of Injury, Quick Fax form, or report the claim on line to VRSA.

Nurse triage services have been successful in providing medical assistance to injured employees and

significantly reducing workers compensation costs. Members that have enrolled have experienced a

reduction in treatment due to home care recommendations where appropriate, panel of physicians being

utilized in lieu of emergency rooms, reduction in time employees are out of work, and significant

improvement in the lag time for reporting claims.

CompCare On-Call Services

VRSA dedicated toll-free number (1-877-234-0898). This number is for VRSA members only.

CompCare On-Call is available 24-7-365

Triage advice provided by a registered nurse

Nurse follow-up with injured employees who receive homecare advice

Immediate access to a registered nurse

CompCare On-Call will review the entire panel of physicians with the employee if the employee is

not provided a panel by the member. ***VRSA recommends that members provide the employee

with a copy of the panel of physicians prior to calling CompCare On-Call, when possible. Doing so,

makes the process easier for the employee and lessens the time the employee is on the phone.

Option available to report an injury only (without nurse intervention). This is available for

supervisors reporting injuries on the employee’s behalf, record only claims, employees that do not

wish to speak with a nurse, etc.

Injury reports sent via secure email

Wallet cards that include the member name and VRSA member number to ensure accuracy of

notification and claim set up

Members will be provided a monthly report of all claims reported.

Following the call, care instructions are sent via text to the employee when home care advice is

provided by the nurse

When treatment is recommended by the nurse and /or the employee plans to seek treatment, a

text is sent to the employee following the call, providing information regarding the physician the

employee selected from the panel (facility, address, and phone number)

A Provider Notice is faxed to the panel physician selected by the employee, notifying the medical

provider the employee is on the way for treatment. The provider notice includes CompCare On-

Call’s nurse triage notes and VRSA’s Medical First Report form. This form includes VRSA’s address,

telephone, and fax number for billing purposes. The medical provider will complete the Medical

First Report with the employee’s work status, fax it to VRSA, and return the report to the employee.

The employee will provide the completed report to their supervisor/employer, so the employer is

aware of the employee’s return to work capabilities or work restrictions.

The first fill prescription card is sent via text to employees that seek medical treatment.

Easy and efficient method for members to provide employee demographics to CompCare On-Call,

which reduces the time employees are on the phone providing this information and ensures

accuracy in reporting.

Coming Soon: A triage phone app for supervisors/managers to download. The app replaces the

need for carrying wallet cards; a supervisor may simply pull up the app and touch to call and report

an injury. Pictures of an injury may also be uploaded and sent to the nurse to better assist with

injuries.

Whitelist Domains to Receive Secure Emails

Injury reports will be sent via secure email to members. Registration and a password are not required to

view, print, and save these reports. To ensure receipt of the secure emails, please whitelist the following

secure email domains:

o S1-medical.com

o Triagenow.net

o Sendgrid.com

o Sendgrid.net

For additional information regarding CompCare On-Call visit our website: www.vrsa.us or contact Robin

Duvall, Director of Workers’ Compensation Claims by calling 1-800-963-6800, Ext. 7340 or via email at:

[email protected]

FOR ADDITIONAL ASSISTANCE WITH

WORKERS’ COMPENSATION MATTERS

PLEASE CONTACT:

Craig W. Smith

HR Coordinator

Office of Human Resources

Phone: (804) 693-7927

Fax: (804) 693-7886

Email: [email protected]

http://www.vrsa.us/

mailto:[email protected]


GLOUCESTER COUNTY SCHOOLS WORKER'S COMPENSATION PANEL OF PHYSICIANS

Rev. 2020-08

THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION. ONCE THE EMERGENCY TREATMENT IS COMPLETED A PANEL

PHYSICIAN MUST BE CHOSEN FOR FOLLOW UP CARE

___ I agree to select a doctor, if needed, from the below panel.

___ I have declined to select a physician from the below panel. I understand that I will have to pay for any medical treatment or doctor's bills, and that I will be denied workers' compensation for any absence based on a disability, which is not certified by an approved panel physician.

_______________________________________________ ___________________

Signature of Employee Date

_______________________________________________ ___________________ Signature of Supervisor Date

M.D. Express Urgent Care – Gloucester 6567 George Washington Memorial Highway | Gloucester, VA 23061 | 804-824-9962

Arakaky, Henry MD McKelvey, Kevin MD Purdy, Carol DO Cleary, Thomas MD Minneci, Peter MD Renforth, Michael MD Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Rizk, Alex MD Forest-Lam, James MD Newton, David MD Rosenberg, David DO Hoyt, Jennifer MD Obie, Eric MD Maulbetsch, Bruce DO Park, Chan MD

M.D. Express Urgent Care – Yorktown 4740 George Washington Memorial Highway Ste A | Yorktown, VA 23692 | 757-890-6339

Arakaky, Henry MD Minneci, Peter MD Purdy, Carol DO Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Renforth, Michael MD Gisanrin, Olu MD Newton, David MD Rizk, Alex MD Hoyt, Jennifer MD Obie, Eric MD Rosenberg, David DO LaBenne, Elisa MD Park, Chan MD Maulbetsch, Bruce DO

Akos Telemedicine -- Offered Through CompCare On-Call (VA) 877-234-0898

Gurrala, Joseph MD Teklu, Abraham MD Valle, Melanie Acevedo MD

GLOUCESTER COUNTY SCHOOLS WORKER'S COMPENSATION PANEL OF PHYSICIANS

Rev. 2020-08

Bon Secours Kilmarnock Primary Care -- Kilmarnock 402 North Main Street | Kilmarnock , VA 22482 | 804-435-2651

Ashworth, Joel MD Ashworth, Joel MD

Dr. Roxanne Dietzler, PC – Newport News 732 Thimble Shoals Blvd. Suite 102 | Newport News, VA 23606 | 757-599-3623

Dietzler, Roxanne DO

M.D. Express Urgent Care – Hampton 3321 West Mercury Blvd. | Hampton, VA 23666 | 757-224-0056

Cochran-Ward, Elizabeth MD Minneci, Peter MD Renforth, Michael MD Gisanrin, Olu MD Moors, William MD Rizk, Alex MD Hoyt, Jennifer MD Newton, David MD Jenkins-Haynie, Lisa MD Obie, Eric MD LaBenne, Elisa MD Park, Chan MD Maulbetsch, Bruce DO Purdy, Carol DO

M.D. Express Urgent Care – Newport News 12997 Warwick Blvd. | Newport News, VA 23602 | 757-369-9446

Arakaky, Henry MD Maulbetsch, Bruce DO Park, Chan MD Cochran-Ward, Elizabeth MD Minneci, Peter MD Purdy, Carol DO Gisanrin, Olu MD Mollenkopf, Holly MD Renforth, Michael MD Hoyt, Jennifer MD Newton, David MD Rizk, Alex MD Jenkins-Haynie, Lisa MD Obie, Eric MD Rosenberg, David DO LaBenne, Elisa MD

M.D. Express Urgent Care – Williamsburg 120 Monticello Ave | Williamsburg, VA 23185 | 757-564-3627

Arakaky, Henry MD Minneci, Peter MD Purdy, Carol DO Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Renforth, Michael MD Hoyt, Jennifer MD Newton, David MD Rizk, Alex MD LaBenne, Elisa MD Obie, Eric MD Rosenberg, David DO Maulbetsch, Bruce DO Park, Chan MD

GLOUCESTER COUNTY SCHOOLS SPECIALIST PANEL

Rev. 2020-08

HANDS TIDEWATER ORTHOPEDICS ASSOCIATES

4037 Ironbound Road | Williamsburg, VA | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA | 757-827-2480

Campolattaro, Robert MD

ORTHOPAEDIC ATLANTIC ORTHOPAEDIC SPECIALISTS

6160 Kempsville Circle Suite 200B | Norfolk, VA 23502 | 757-321-3386

Butkovich, Bradley MD Cohn, Sheldon MD Warren, Paul MD Byrd, J. Abbott III

ORTHOPAEDIC HAMPTON ROADS ORTHOPAEDICS & SPORTS MEDICINE

730 Thimble Shoals Boulevard, Suite 130 | Newport News, VA 23606 | 757-873-1554

Baddar, Adrian MD Cavazos, Daniel MD Swenson, Jon MD Carter, Anthony MD

ORTHOPAEDIC ORTHOPAEDIC AND SPINE CENTER (OSC)

250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900

Burow, John D. DO Carlson, Jeffrey MD

ORTHOPAEDIC RIVERSIDE ORTHOPEDIC SPECIALISTS

120 Kings Way Suite 2700 | Williamsburg, VA 23188 | 757-645-0145

Barley, IV John DO Kling, Scott R. MD

ORTHOPAEDIC TIDEWATER ORTHOPAEDICS ACCOCIATES

4037 Ironbound Road | Williamsburg, VA 23188 | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480

an- Higgins, Michael MD


Rev. 2020-08

ORTHOPAEDIC

VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS 2012 Meade Parkway | Suffolk, VA 23434 | 757-673-5680

Huttman, Daniel T. MD

ORTHOPAEDIC VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS

3300 High Street, Suite 1 | Portsmouth, VA 23707 | 757-673-5680 5838 Harborview Blvd. Suite 100 | Suffolk, VA 23434 | 757-673-5680

Blasdell, Steven MD Huttman, Daniel T. MD Marlow, Aaron MD

ORTHOPAEDIC – BACK & SPINE TIDEWATER ORTHOPAEDICS ASSOCIATES


an- Mason, Jonathan R. MD

ORTHOPAEDIC – BACK & SPINE VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS

MAST One Bldg., 1040 University Blvd. #200 | Portsmouth, VA 23707 | 757-673-5680

an- Kerner, Mark MD

ORTHOPAEDIC – FOOT & ANKLE ATLANTIC ORTHOPAEDIC SPECIALISTS


an- Campbell, Michael MD

ORTHOPAEDIC – FOOT & ANKLE RIVERSIDE ORTHOPEDIC SPECIALISTS

120 Kings Way Suite 2700 | Williamsburg, VA 23188 | 757-645-0145

Vargo, Robin MD


Rev. 2020-08

ORTHOPAEDIC – HAND & UPPER EXTREMITY ATLANTIC ORTHOPAEDICS ASSOCIATES


an- Manke, Chad MD

ORTHOPAEDIC – HAND & UPPER EXTREMITY TIDEWATER ORTHOPAEDICS ASSOCIATES

901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480

an- Smerlis, Nicholas MD

ORTHOPAEDIC – SHOULDER SURGERY HAMPTON ROADS ORTHOPAEDICS & SPORTS MEDICINE

730 Thimble Shoals Boulevard, Suite 130 | Newport News, VA 23606 | 757-873-1554

Fithian, Thomas MD

ORTHOPAEDIC – SHOULDER SURGERY ORTHOPAEDIC AND SPINE CENTER (OSC)

250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900 Coleman, Martin MD

ORTHOPAEDIC – SHOULDERS & KNEES ORTHOPAEDIC AND SPINE CENTER (OSC)

250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900 Haynes, III Boyd MD

ORTHOPAEDIC – SHOULDERS & KNEES TIDEWATER ORTHOPAEDICS ASSOCIATES


an- Payne, Loell MD Saban, Nicholas MD

Work Comp Medical First Report 1. To be completed by the treating physician - Please send completed forms to Virginia Risk Sharing Association

(VRSA) - fax 800-273-4865

2. Please provide the patient with a copy of the completed form.

3. Patient, provide your supervisor with a copy of this form after treating.

Patient’s Name: ____________________________________________________________________

Patient’s Address: ____________________________________________________________________

Name of Employer: ____Gloucester County Public Schools ________________________________

Date of Accident or Illness: ____/ ____/ ____

Patients account of How Injury or Exposure Occurred: _____________________________________________

_________________________________________________________________________________________

Name of Medical Facility: ___________________________________________________________________

Date of Visit: ____/ ____/ ____ Arrival Time: ___________ AM/PM Departure Time: ____________ AM/PM

Diagnosis: ___________________________________________________________________________

New Injury/Illness Existing Condition

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Recommended Work Status:

A) May return to full duty beginning: ____/ ____/ ____

B) May return to modified duty beginning: ____/ ____/ ____

Recommendation based on:

______personal review of functional job description

______verbal description of job by employee/patient

______verbal description of job by employer representative

______other (describe:______________________________________________ )

The employee/patient is medically able to do the following activities:

_______________________________________________________________

_______________________________________________________________

Does condition preclude travel to and from work Yes No

Does condition preclude being at work Yes No

Anticipate return to full duty beginning: ____/ ____/ ____

C) Unable to work at this time

Anticipate return to modified duty beginning: ____/ ____/ ____

Anticipate return to full duty beginning: ____/ ____/ ____

Physician’s Comments (Please note any contributing factors, prior injuries and pre-existing conditions):

____________________________________________________________________________________________

____________________________________________________________________________________________

Follow-Up Appointment with: _______________________________ Date: ____/ ____/ ____ Time: __ ________ AM/PM

To ensure payment, any follow-up care must be authorized by Virginia Risk Sharing Association (VRSA)

Physician/Clinician Name (please print): _____________________________________Phone #_______________

Physician/Clinician Signature: ___________________________________________________________________

VRSA Billing Address: P. O. Box 182480, Columbus, OH 43218-2480 Tel.: 800-963-6800

Fax: 800-273-4865

Workers’ Compensation

First Fill Prescription Form Instructions

With this form, a 10 day supply of medication will be provided to the injured employee at no cost.

Instruct the injured employee to take this form to a network pharmacy and present this to the

pharmacy with their prescription(s).

The network includes all major chains (CVS, Rite Aid, Wal-Mart, K-Mart, Target, etc.) as well as most

of the medium and small local pharmacies. To view the pharmacy network or find a local pharmacy,

visit our pharmacy provider’s website at www.Aliushealth.com Click on the ‘Pharmacy Locator’ tab.

Once the claim is received and reviewed by Virginia Risk Sharing Association (VRSA), VRSA will let the

pharmacy provider know if the claim is accepted or denied. If accepted, the remaining supply of

medication will be filled. Any future prescriptions the injured employee needs will be direct billed

through the pharmacy provider. A pharmacy representative will also contact the injured employee

and explain the process. If the claim is denied, there is no financial consequence to the injured

employee for the first fill.

Important Information and Instructions for providing a first fill form to an injured employee:

This form is for workplace injuries only

A workers’ compensation claim must be reported to VRSA by calling CompCare On-Call,

nurse triage and reporting service: 1-877-234-0898

Before providing this form to the employee:

o Add the employee’s legal name

o Add the last 4 digits of the employee’s social security number to the Member ID:

ALIUSVRSA (for example: ALIUSVRSA1234).

o Add the date of injury

Provide this form to an employee immediately following the injury. Employees that do not

plan to seek treatment should not be provided this form.

This form is valid for one time use only. Do not provide an employee with additional

forms for the same injury. For additional medication beyond the first fill, the injured

employee must contact their VRSA claims representative: 1-800-963-6800.

Craig W. Smith

HR Coordinator

Office of Human Resources

Phone: (804) 693-7927

Fax: (804) 693-7886

Email: [email protected]

http://www.aliushealth.com/


First Fill Instructions for VRSA Members

Dear Injured Worker, This is your temporary prescription card allowing up to a 10-day supply of medication at no cost. This card is for workplace incidents only and valid for one time use only.

Prior to presenting this card please add your first and last name, the last four digits of your social security number (SSN), and date of accident in the in the required fields. Present this card along with your prescription(s) to a participating pharmacy. Our extensive pharmacy network includes most major chains and many local pharmacies (some participating pharmacies are listed below). To view the pharmacy network or find a local pharmacy visit our website www.Aliushealth.com or call 844-661-4463.

Employee Name:

Member ID:

Add Last 4 Digits of patient’s SSN (Example: ALIUSVRSA1234)

RxGroup #: ALHFF08201701 RxBIN/IIN: 610729 RxPCN: ALIUS Person Code: 01 Date of Injury: ATTENTION PHARMACISTS: Please process prescriptions through Script Care.

For rejected claims, please call Alius Health at

844-661-4463. ATTENTION INJURED WORKER: The use of this

prescription card is restricted to your allowed injury

condition only. If the pharmacy staff advises that they are

unable to fill your medications due to a rejection, please

call 844-661-4463 for assistance.

*In some instances, an individual pharmacy may be removed from the network due to non-conformity

Walmart Kroger Target

Harris Teeter Wegmans Safeway

Sam’s club Food Lion CVS

Rite-Aid Costco Giant

Estimado Trabajador,

Alius Health es socio de VRSA a sido seleccionado para administrar su plan de medicamentos recetados para su lesiones.

Aquí esta su tarjeta de prescripción temporal que permite hasta 10 días de medicamento. Antes de presentar su tarjeta

porfavor ponga su nombre completo y los ultimos cuatro digitos de su securo social en el área indicada. Una vez que su

reclamación ha sido aceptada por VRSA se le enviara una tarjeta de reemplazo para requerir tratamiento continuo. La

tarjeta nueva le va a permitir medicamentos mensualmente relacionados a su lesion.

Nuestra extensa red de farmacias include las siguientes. Simplemente present esta tarjeta junto con su recetas a una

farmacia participantes. Para verificar si su farmacia preferida esta en nuestra red de farmacias puede utilizar nuestro

localizador de farmacia en www.Aliushealth.com o llamar 844-661-4463.

ALIUSVRSA



IF AN INJURY OCCURS AT WORK, YOU MUST

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