Worker’s CompensationWorkshop

Procedure for Processing a Worker’s Compensation Claim

The Office of Human Resources

The Mission of the State Government Worker’s

Compensation Program is to ensure ethical and equitable

treatment of injured employees in a cost efficient

manner.

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What Constitutes a Worker’s Comp. Claim?

An On-the-job injury due an incident occurring on or off

campus.

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Who is Covered?

• Permanent Employees• Temporary Employees• Part-Time Employees• Working Students

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Who is Not Covered?

• Independent Contractors• Non-Working Students

Supervisor’s Responsibilities• Ensure that the injured employee receives

immediate and appropriate medical attention

• Direct the employee to the authorized primary care physician

• Complete the required NCIC Form 19 and forward to the Worker’s Compensation Administrator within 24 hours of the injury

• Assist in the accident investigation to determine the cause of the accident

• Correct unsafe conditions immediately• Communicate with injured employees to

ensure their needs are met. If the employee is out of work make contact weekly.

• Report the total number of days missed due to injury to the WC Administrator

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Authorized Primary Care Physician

Prime Care of Highland Oaks600 Highland Oaks DriveWinston Salem, NC 27103(336) 774-0044

If it is a life threatening emergency, or after hours go to the nearest medical

facility

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Filing a Claim

• Contact HR for a Form 19 and Medical Authorization Form

• Complete a NC Industrial Commission Form 19 (Employee must sign and date form on the back)

• Send the Form 19 to Benefits Rep. in Human Resources

• Give the injured employee the Medical Authorization Physician’s Report write “No Drug Test” in the upper right corner

• Send the employee to the care provider listed on the Quick Reference Guide

• Employee should return the Medical Authorization form to his/her supervisor or office manager to forward to HR

• If he/she is given a prescription please send them to one of the pharmacies listed on the reverse side of the Quick Reference Guide for Employees.Encourage Safe Work Encourage Safe Work PracticesPractices

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Forms

Medical Authorization Form

http://www.keyrisk.com/pdfs/claimsPharmacy-PhysiciansReport.pdf

If the employee has to be rushed to an emergency facility, this form can be waived for a hospital report form.

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Prescription Pharmacy Form

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In case of an extreme emergency and the injured employee is taken to the emergency room; The same forms are needed. A police report must be filed with the form 19 and the Medical Authorization Form or a hospital report form.

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What Do I Do If an Employee Refuses Treatment?

• Notify Mary Ellen Haynes in Human Resources

Note: An employee can still file a claim within the 2-year period

allowed by law, even if a release statement of Refusal of

WC Benefit was provided.

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WC Leave Policy

Day of InjuryNo leave is charged on the day of

the injury if the treating physician instructs the employee not to return to work and provides a statement

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WC Leave Policy

Leave OptionsElect to take sick or vacation

leave during the required waiting period and then go on WC leave and begin drawing WC weekly benefits.

Elect to go on WC leave with no pay for the required waiting period and then begin drawing WC weekly benefits.

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Worker’s Compensation Administrator

Mary Ellen Haynes, Benefits Representative

770-1451haynesm@ncarts.edu

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