ࡱ> u@ [bjbj ST`L`L`L`LL3bN0O0O0O0OQQQaaaaaaa$!cRseaQ7Q^QQQa0O0OaUUUQ0O0OaUQaUU)UgUKU0ON @ߨw `L[SFUV b03bUGfSfGfUGfUDUQQQaaHKU K DIVISION OF WORKERS COMPENSATION EMPLOYEE ASSISTANCE AND OMBUDSMAN OFFICE PRESENTS REPORTING THE CLAIM HRM Conference: Collaboration at Work. November 14th and 15th, 2006 Presenter: Division of Risk Management Bureau of State Employees' Workers' Compensation Claims Lisel M. Laslie ( HYPERLINK "mailto:Lisel.Laslie@fldfs.com" Lisel.Laslie@fldfs.com) First Report of Injury: When an employee is injured at work, by statute they have 30 days to report the claim to the employer. Failure to report the claim within the 30 days may be used as a defense against the claim regardless of the two-year statute of limitations for filing a claim. As employers, when you know about an injury suffered by an employee call the First Intake Unit at 1-866-786-3351. Calls are accepted 24 hours per day 7 days per week. The intake unit will take the information and refer the employee for care as needed. A report (Exhibit A) is created and then sent to Risk Management and to the employer. 13 Week Wage Statements: Once the First Report of Injury is called in, you may contact the Specialist assigned to the file at DRM. (Exhibit B- Map of Florida showing Specialist assignments). A 13 Week Wage Statement is required in the event that the employee will need to receive indemnity benefits from DRM. (Exhibit C). Authority for Alternate Duty: Section 216.251(1)(b)2, FS: When the Division of Risk Management of the Department of Financial Services has determined that an employee is entitled to receive a temporary partial disability benefit or a temporary total disability benefit pursuant to the provisions . of s. 440.15 and there is medical certification that the employee cannot perform the duties of the employee's regular position, but the employee can perform some type of work beneficial to the agency, the agency may return the employee to the payroll, at his or her regular rate of pay, to perform such duties as the employee is capable of performing, even if there is not an established position in which the employee can be placed. Nothing in this subparagraph shall abrogate an employee's rights under chapter 440 or chapter 447, nor shall it adversely affect the retirement credit of a member of the Florida Retirement System in the membership class he or she was in at the time of, and during, the member's disability. DRM Medical Case Management RFP: DRM issued an RFP requesting bids on a new model for medical case management. The projected conversion date is early 2007. The new model will encourage: Medical Case Management on pre-defined criteria based on objective findings; Proper completion and use of DWC-25; Medical providers will assess functional restrictions; Employer will determine work status based on functional restrictions; Improved communication between case management, State agencies and DRM; and Keeping employee at work. Weekly Indemnity Report: DRM will provide weekly report via email to named recipient. The report distribution is based on DRM 4-digit location code, and may be provided at Department level or any sub-level provided within location code list. For more information on the report, or to be a named recipient of the report, contact Lisel Laslie at Lisel.Laslie@fldfs.com. Website:  HYPERLINK "http://www.fldfs.com/Risk/WCC/index.html includes:" http://www.fldfs.com/Risk/WCC/index.html includes: Facts for Florida Employees; Frequently asked questions; DRM claim assignment information; Medical case management information; Workers' compensation forms; and Employer Handbook Division of Risk Management Bureau of State Employees' WC Claims FIRST REPORT OF INJURY OR ILLNESSRECEIVED BY CLAIMS HANDLING ENTITYSENT TO DIVISION DATEDIVISION RECEIVED DATEFLORIDA DEPARTMENT OF FINANCIAL SERVICES DIVISION OF WORKERS' COMPENSATION For assistance call 1-800-342-1741 or contact your local EAO Office Report all deaths within 24 hours 1-800-219-8953 or (850) 922-8953PLEASE PRINT OR TYPE EMPLOYEE INFORMATION Name (First, Middle, Last) LISEL LASLIESocial Security Number 123-45-6789Date of Accident (Month-Day-Year) 04/26/2006Time of Accident 3:15 PMHome Address Street/Apt #: 1800 HERMITAGE BLVD City: TALLAHASSEE State: FL Zip: 32311Employee's Description of Accident (Include Cause of injury) WHILE ATTEMPTING TO BREAK UP A FIGHT BETWEEN TWO RESIDENTS, EMPLOYEE WAS STRUCK ON THE RIGHT SIDE OF HIS FACE ON THE CHEEK BONE. Telephone: Area Code Number (850) 413-4832Occupation 5793/UNIT TREATMNT & REHAB SR SUPV I-F/C -SESDATE OF BIRTH 05/07/1969SEX FINJURY/ILLNESS THAT OCCURED ContusionPART OF BODY AFFECTED Other Facial Soft Tissue EMPLOYER INFORMATION Company DEPT OF CHILDREN & FAMILIES D.B.A.: FLORIDA STATE HOSPITAL Contact: MICKEY MOUSE Street: 1317 WINEWOOD BLVD City: TALLAHASSEE State : FL Zip: 32399 FEDERAL ID NUMBER (FEIN) DATE FIRST REPORTED 04/27/2006NATURE OF BUSINESSPOLICY/MEMBER NUMBERTelephone Number: Area Code Number (850) 487-1111DATE EMPLOYED 03/09/1990PAID FOR DATE OF INJURYEmployer's Location Address (if different) Street: 1801 HERMITAGE BLVD City:TALLAHASSEE State:FL Zip:32311 Location #(if applicable) : 7519LAST DATE EMPLOYEE WORKED WILL YOU CONTINUE TO PAY WAGES INSTEAD OF WORKERS COMP? LAST DAY WAGES WILL BE PAID INSTEAD OF WORKERS COMPRETURNED TO WORK YES IF YES, GIVE DATE 04/26/2006 RATE OF PAY 2161.56 PER HourWeekDayMonthXPlace of Accident (Street, City, State, Zip) Street: SAME City: State: FL Zip: County of Accident: LEONDATE OF DEATH (If applicable)Number of hours per day 8 Number of hours per week 40.00 Number of days per week 5AGREE WITH DESCRIPTION OF ACCIDENT YES Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits insurance fraud, punishable as provided in s. 817.234. Section 440.105(7), F.S. I have reviewed, understand and acknowledge the above statement. _____________________________________ ___04/27/2006____ Employee Signature Date _____________________________________ ___04/27/2006____ Employer Signature Date NAME, ADDRESS AND TELEPHONE OF PHYSICIAN OR HOSPITAL Physician: () - Hospital: FAMILY MEDICAL CLINIC, 225 CAPITAL CIRCLE NE TALLAHASSEE, FL 32312 (850) 668-9545AUTHORIZED BY EMPLOYER XYesNo CLAIMS-HANDLING ENTITY INFORMATION 1(a) Denied Case - DWC-12, Notice of Denial Attached2. Medical Only which became Lost Time Case (Complete all required information in #3)1(b) Indemnity Only Denied Case - DWC-12, Notice of Denial AttachedEmployees 8TH Day of Disability _______ / ______ / _______Entitys Knowledge of 8TH Day of Disability ______ / _______ / _______3. Lost Time Case - 1st day of disability ____ / ____ / ____Full Salary in lieu of comp?YESFull Salary End Date ______/ ______ / ______ Date First Payment Mailed _________ / _________ / _________ AWW ____________________________ Comp Rate ____________________________T.T.T.T. - 80%T.P.I.B.P.TDEATHSETTLEMENT ONLY Penalty Amount Paid in 1st Payment $___________ Interest Amount Paid in 1st Payment $__________REMARKS:INSURER NAME DIVISION OF RISK MANAGEMENT, STATE OF FLORIDA CLAIMS-HANDLING ENTITY NAME, ADDRESS & TELEPHONE DIVISION OF RISK MANAGEMENT, STATE OF FLORIDA PO BOX 8020 TALLAHASSEE FL 32314 (850) 413-3123INSURER Code 9235EMPLOYEE'S CLASS CODEEMPLOYER'S NAICS CODEService Co/TPA Code # 6026CLAIMS-HANDLING ENTITY FILE # 05 73001551Form DFS-F2-DWC-1 (08/2004) WAGE STATEMENT FLORIDA DEPARTMENT OF LABOR AND EMPLOYEMENT SECURITY DIVISION OF WORKERS COMPENSATION NOTICE TO EMPLOYEE: If you have any questions about the information contained on this form, please contact your employer or insurance carrier. If further assistance is needed, contact the Divisions Employee Assistance Office at 1-800-342-1741.FOR CARRIERS DATE STAMP RECD BY CARRIER PLEASE PRINT OR TYPEEMPLOYEE NAME LISEL LASLIESOCIAL SECURITY NUMBER 123-45-6789DATE OF ACCIDENT 04/26/2006EMPLOYER NAME & ADDRESS Department of Children and Families 1317 Winewood Blvd Tallahassee, FL 32399 CONCURRENT EMPLOYER NAME & ADDRESS ARE THE WAGES LISTED BELOW FOR A SIMILAR EMPLOYEE? ____YES __ __NOSIMILAR EMPLOYEES NAMEEmployees Customary Work Week (ex. Saturday thru FridayUse 7 calendar day period)Employees Customary Days Worked / Week (ex. 5 days / week)Employees Customary Hours Worked / Week (ex. 40 hours / week)Occupation of Similar EmployeeNOTICE TO EMPLOYER: Please read all instructions on the back of this form carefully. Complete the form as fully as possible and submit it to your carrier within 14 days after knowledge of any accident that has caused your employee to be disabled for more than 7 calendar days. If you discontinue providing any fringe benefits your must file a corrected Wage Statement with your carrier within 7 days of such termination, reflecting the type and amount of fringe benefits that were paid, and the last date they were provided.Please list wages earned for the 91 day period immediately preceding the accident. DO NOT combine wages of two or more employees.GRATUITIES AS REPORTED TO THE EMPLOYER IN WRITING AS TAXABLE INCOMEFRINGE BENEFITS (employee recd) EMPLOYER COST ONLY WEEK NO.WEEK# OF DAYS WORKED THAT WEEK# HOURS WORKED THAT WEEK GROSS PAYHEALTH INSURANCERENT / HOUSINGFROM TO101/22/0601/28/06540502.69182.00201/29/0602/06/06540502.69302/07/0602/13/06540502.69182.00402/14/0602/20/06540502.69502/21/0602/27/06540502.69182.00602/28/0603/06/06540502.69703/07/0603/13/06540502.69182.00803/14/0603/20/06540502.69903/21/0603/27/06540502.69182.001003/28/0604/03/06540502.691104/04/0604/10/06540502.69182.001204/11/0604/17/06540502.691304/18/0604/24/06540502.6914 RETURN THIS FORM TO: (Carrier name, Address & Telephone #) TOTAL6534.97WILL EMPLOYER CONTINUE TO PROVIDE ABOVE BENEFITS? ___YES ___NO ___YES ___NO TOTAL FRINGE BENEFITS$ 1092.00 TOTAL OF GROSS PAY, GRATUITIES AND FRINGES$ 7626.97 (FOR CARRIER USE ONLY)AWW 502.69COMP RATE 335.12Any person who, knowingly and with intent to injure, defraud or deceive any employer or employee, insurance company or self-insured program, files a statement of claim containing any false or misleading information, is guilty of a felony in the third degree. ______________Minnie Mouse ____________ ___________413-9999______________ ______04/28/2006____ PREPARERS NAME TELEPHONE # DATE 440.185 Notice of injury or death; reports; penalties for violations.-- (1)An employee who suffers an injury arising out of and in the course of employment shall advise his or her employer of the injury within 30 days after the date of or initial manifestation of the injury. Failure to so advise the employer shall bar a petition under this chapter unless: (a)The employer or the employer's agent had actual knowledge of the injury; (b)The cause of the injury could not be identified without a medical opinion and the employee advised the employer within 30 days after obtaining a medical opinion indicating that the injury arose out of and in the course of employment; (c)The employer did not put its employees on notice of the requirements of this section by posting notice pursuant to s.  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/Sec055.HTM" 440.055; or (d)Exceptional circumstances, outside the scope of paragraph (a) or paragraph (b) justify such failure. In the event of death arising out of and in the course of employment, the requirements of this subsection shall be satisfied by the employee's agent or estate. Documents prepared by counsel in connection with litigation, including but not limited to notices of appearance, petitions, motions, or complaints, shall not constitute notice for purposes of this section. (2)Within 7 days after actual knowledge of injury or death, the employer shall report such injury or death to its carrier, in a format prescribed by the department, and shall provide a copy of such report to the employee or the employee's estate. The report of injury shall contain the following information: (a)The name, address, and business of the employer; (b)The name, social security number, street, mailing address, telephone number, and occupation of the employee; (c)The cause and nature of the injury or death; (d)The year, month, day, and hour when, and the particular locality where, the injury or death occurred; and (e)Such other information as the department may require. The carrier shall, within 14 days after the employer's receipt of the form reporting the injury, file the information required by this subsection with the department. However, the department may by rule provide for a different reporting system for those types of injuries which it determines should be reported in a different manner and for those cases which involve minor injuries requiring professional medical attention in which the employee does not lose more than 7 days of work as a result of the injury and is able to return to the job immediately after treatment and resume regular work. (3)In addition to the requirements of subsection (2), the employer shall notify the department within 24 hours by telephone or telegraph of any injury resulting in death. However, this special notice shall not be required when death results subsequent to the submission to the department of a previous report of the injury pursuant to subsection (2). (4)Within 3 days after the employer or the employee informs the carrier of an injury the carrier shall mail to the injured worker an informational brochure approved by the department which sets forth in clear and understandable language an explanation of the rights, benefits, procedures for obtaining benefits and assistance, criminal penalties, and obligations of injured workers and their employers under the Florida Workers' Compensation Law. Annually, the carrier or its third-party administrator shall mail to the employer an informational brochure approved by the department which sets forth in clear and understandable language an explanation of the rights, benefits, procedures for obtaining benefits and assistance, criminal penalties, and obligations of injured workers and their employers under the Florida Workers' Compensation Law. All such informational brochures shall contain a notice that clearly states in substance the following: "Any person who, knowingly and with intent to injure, defraud, or deceive any employer or employee, insurance company, or self-insured program, files a statement of claim containing any false or misleading information commits a felony of the third degree." (5)Additional reports with respect to such injury and of the condition of such employee, including copies of medical reports, funeral expenses, and wage statements, shall be filed by the employer or carrier to the department at such times and in such manner as the department may prescribe by rule. In carrying out its responsibilities under this chapter, the department or agency may by rule provide for the obtaining of any medical records relating to medical treatment provided pursuant to this chapter, notwithstanding the provisions of ss.  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0090/Sec503.HTM" 90.503 and  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0395/Sec3025.HTM" 395.3025(4). (6)In the absence of a stipulation by the parties, reports provided for in subsection (2), subsection (4), or subsection (5) shall not be evidence of any fact stated in such report in any proceeding relating thereto, except for medical reports which, if otherwise qualified, may be admitted at the discretion of the judge of compensation claims. (7)Every carrier shall file with the department within 21 days after the issuance of a policy or contract of insurance such policy information as the department requires, including notice of whether the policy is a minimum premium policy. Notice of cancellation or expiration of a policy as set out in s.  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/Sec42.HTM" 440.42(3) shall be mailed to the department in accordance with rules adopted by the department under chapter 120. The department may contract with a private entity for the collection of policy information required to be filed by carriers under this subsection and the receipt of notices of cancellation or expiration of a policy required to be filed by carriers under s.  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/Sec42.HTM" 440.42(3). The submission of policy information or notices of cancellation or expiration to the contracted private entity satisfies the filing requirements of this subsection and s.  HYPERLINK "http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/index.cfm?App_mode=Display_Statute&Search_String=&URL=Ch0440/Sec42.HTM" 440.42(3). (8)When a claimant, employer, or carrier has the right, or is required, to mail a report or notice with required copies within the times prescribed in subsection (2), subsection (4), or subsection (5), such mailing will be completed and in compliance with this section if it is postmarked and mailed prepaid to the appropriate recipient prior to the expiration of the time periods prescribed in this section. (9)Any employer or carrier who fails or refuses to timely send any form, report, or notice required by this section shall be subject to an administrative fine by the department not to exceed $1,000 for each such failure or refusal. If, within 1 calendar year, an employer fails to timely submit to the carrier more than 10 percent of its notices of injury or death, the employer shall be subject to an administrative fine by the department not to exceed $2,000 for each such failure or refusal. However, any employer who fails to notify the carrier of the injury on the prescribed form or by letter within the 7 days required in subsection (2) shall be liable for the administrative fine, which shall be paid by the employer and not the carrier. Failure by the employer to meet its obligations under subsection (2) shall not relieve the carrier from liability for the administrative fine if it fails to comply with subsections (4) and (5). (10)The department may by rule prescribe forms and procedures governing the submission of the change in claims administration report and the risk class code and standard industry code report for all lost time and denied lost-time cases. The department may by rule define terms that are necessary for the effective administration of this section. (11)Upon receiving notice of an injury from an employee under subsection (1), the employer or carrier shall provide the employee with a written notice, in the form and manner determined by the department by rule, of the availability of services from the Employee Assistance and Ombudsman Office. The substance of the notice to the employee shall include: (a)A description of the scope of services provided by the office. (b)A listing of the toll-free telephone number of, the e-mail address, and the postal address of the office. (c)A statement that the informational brochure referred to in subsection (4) will be mailed to the employee within 3 days after the carrier receives notice of the injury. (d)Any other information regarding access to assistance that the department finds is immediately necessary for an injured employee. History.--s. 10, ch. 75-209; s. 1, ch. 77-174; ss. 6, 23, ch. 78-300; ss. 14, 124, ch. 79-40; ss. 10, 21, ch. 79-312; s. 6, ch. 80-236; s. 276, ch. 81-259; s. 6, ch. 83-305; s. 8, ch. 86-171; s. 5, ch. 87-330; s. 5, ch. 88-203; ss. 14, 43, ch. 89-289; ss. 22, 56, ch. 90-201; ss. 20, 52, ch. 91-1; s. 29, ch. 91-46; s. 82, ch. 92-289; s. 22, ch. 93-415; s. 112, ch. 97-103; s. 4, ch. 98-125; s. 9, ch. 98-174; s. 3, ch. 98-407; s. 93, ch. 2000-153; s. 15, ch. 2001-91; s. 29, ch. 2002-194; s. 21, ch. 2003-412; s. 13, ch. 2004-6. 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