RM-10 Rev. 7 Workers' Compensation Claims AdministrationCITY OF DELRAY BEACH
ADMINISTRATIVE POLICIES AND PROCEDURES
DEPARTMENT:
SUBJECT:
Risk Management
Workers'Compensation
Claims Administration
POLICY NUMBER:RM-10
SUPERSEDES:RM-10,Rev.6
REVISION:
APPROVED BY:
PURPOSE
CTIVE DATE:/1 2z
Terrence R.Moore,ICMA-CM
The purpose of this policy is to establish procedures for filing the First Report of Injury or Illness (Attachment
A)and for the administration of workers'compensation claims as required by the State of Florida.
PROCEDURE
A.Claims Administration Service
The following are third party claims administrators {TPA)who in accordance with Florida Statues Chapter
440,Workers'Compensation administer the City's workers'compensation claims:
a.Preferred Governmental Claim Solutions (PGCS)provides third party claims administration
services for accidents dated October 1,2013 to present.PGCS will provide the managed medical
care administration.
b.Accidents dated October 1,1989 to September 30,2013 are sent to Gallagher Bassett Services.
c.Accidents dated October 1,1985 to September 30,1989 are sent to Florida League of Cities.
d.Accidents dated October 1,1982 to September 30,1985 are sent to Gallagher Bassett Services.
e.Accidents dated prior to October 1,1982 are sent to Hewitt Coleman and Associates.
8.First Report of Injury or Illness
1.If an on-the-job injury occurs during normal work hours,the Administrative Assistant will provide
basic accident information by e-mail immediately to Risk Management (See Attachment G "Initial
Notice of W/C Injury").For department/division name and code to which the accident is to be
charged (See Attachment B).
2.If an on-the-job injury occurs after normal work hours,the Administrative Assistant will provide basic
accident information by e-mail to Risk Management on the first full workday following the injury (See
Attachment G).For department/division name and code to which the accident is to be charged
(See Attachment B).
Workers'Compensation Claims Administration
RM-1O,Rev.6
Page 2 of 15
3.Risk Management immediately will e-mail this accident information to TPA (and others considered
necessary by Risk Management).This e-mailing of accident information is simply intended to
expedite the provision of medical care and claims administration.
4.For all on-the-job injuries/illnesses,regardless of the extent of an injury/illness,an original,fully
completed First Report of Injury or Illness (Attachment A)signed at least by the employee's
supervisor,will be sent by the Administrative Assistant to Risk Management within 48 hours after
an accident.Attachment A shows certain information which must be included.Sending a First
Report should not be delayed pending management signature;a supervisor's signature is
acceptable.Nor should it be delayed pending the injured employee's signature.If applicable,the
"Employee Signature"line should state:"Employee not available".The State can impose fines for
late reporting.However,all First Reports (original or copy)must eventually be signed by the
appropriate Department and Division Heads and sent to Risk Management.
5.Employee must report to their supervisor ALL injury or illness occurring during their work hours,
regardless of the extent or nature.Not only could a delay in reporting jeopardize an employee's
coverage under workers'compensation law,but a delay could result in medical complication and/or
unnecessary medical care.
6.Risk Management will send the original First Report to TPA on the day received.TPA must properly
report the claim to the State within 14 calendar days.
7.The First Report must include the Administrative Assistant's name,telephone number and the
department/division name and code to which the accident is to be charged (See Attachment B).
This person will be TPA's departmental contact.
C.Accident Investigation Report,Workers'Compensation
1.An original,fully executed Accident Investigation Report,Workers'Compensation (Attachment C)
will be sent by the Administrative Assistant to Risk Management as soon as possible,but no later
than the third full workday after an accident.This should allow the department time to fully
investigate the accident.The Safety Coordinator can always be asked to assist.
2.Risk Management will send a copy to the TPA
D.Request for Full Pay During Workers'Compensation Absence
1.As applicable per Personnel Policy Manual,Section 12.1,"On the Job Injury",or union contract,
employees who are absent from work duty because of a work-related illness or injury can receive
their full pay for a period of ninety (90)consecutive calendar days,beginning at the employee's
discretion.
2.The employee must execute the "90-Day Benefit Form"(Attachment D).The Administrative
Assistant will complete the "90 Days paid through"section at the bottom and distribute as indicated
no later than the Friday proceeding the next payday.If not received on time,payroll will presume
the start date to be the date of the accident.
3.The Administrative Assistant will verify and properly record workers compensation pay codes
(Attachment E)on the employee's timesheet.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 3 of 15
E.Wage Statement
1.To enable the correct calculation of wage benefits due under the workers'compensation law,the
City is required to provide TPA with specific wage information of the injured employee.
2.If necessary,Risk Management will send an e-mail (Attachment H)to the Administrative Assistant
requesting specific wage information to enable the benefit calculation.
3.The Administrative Assistant will complete and return this e-mail to Risk Management as soon as
possible but no later than the third full workday.
F.Initial Medical Care
1.If emergency medical treatment is required;"9-911"will be called immediately.If any doubt,"9-
911"should be called.No prior authorization is required for emergency medical treatment.
2.If non-emergency medical treatment is required,the employee must report the accident to the
supervisor.The supervisor will make sure the injured employee goes to a local medical facility with
which the City has arranged for initial medical care.
3.If medical treatment is required after "normal"work hours (e.g.,nights,holidays),of typically used
medical facilities,the injured employee will obtain medical care from Delray Medical Center or
Bethesda Hospital.However,the employee should follow up with the City's local medical facility as
directed by the supervisor.
4.If medical care is requested by the employee,a First Report must be completed by the Department
and properly distributed,and initial medical care provided.
5.If medical care is deemed necessary by the Department but the employee refuses medical care,A
First Report must be completed by the Department and properly distributed,indicating in the block
entitled "Name,Address and Telephone of Physician or Hospital":Employee refused medical care".
6.If medical care initially does not appear necessary because of a very minor accident,a First Report
must be completed as in "D"above,but in the block entitled "Name,Address and Telephone of
Physician or Hospital",the following wording must be stated:"Initial medical care not considered
necessary by the department or employee."The supervisor must follow up with the employee to
make sure this medical condition does not worsen and subsequently require medical care.
7.The employee should identify themselves at the medical facility as a City of Delray Beach employee
by either presenting the Medical Care &Work Authorization form (Attachment F)which is provided
by the Administrative Assistant or their City picture identification card.If necessary,the
Administrative Assistant or Supervisor may be contacted by the local medical facility to confirm City
employment.
The employee must inform the medical facility that treatment is required due to an on-the-job injury.
8.An injured employee should never be denied "unauthorized"medical care if considered urgent and
necessary.Unless considered urgent,emergency medical providers (e.g.,referral by the
emergency room doctor or the EMT's)cannot authorize workers'compensation medical care;only
the Risk Manager can,or the TPA at the Risk Manager's direction.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 4 of 15
G.Authorization for Medical Care
1.The City has arranged with a local medical facility to provide initial medical are during "normal"work
hours.Such facilities and hours of operation will be publicized in each department by Risk
Management.
2.The medical provider will fax to TPA all medical documents and referrals (e.g.,specialists,x-rays,
etc.)
3.TPA will contact the employee and authorize all medical care.
4.Once TPA has authorized any physician,employee is responsible to schedule follow-up
appointments.
5.The employee should take prescriptions to any major pharmacy chain.Attachment I is a
memorandum sent to all Administrative Assistants which explains the procedure to follow for the
employee to obtain necessary and discounted medications prescribed by their authorized treating
physician(s).
6.The employee is required to report to the department on their work status immediately after any
medical care,including physician's written verification of that status.
7.The department may call the treating physician,TPA or Risk Management if there are questions
related to the claim,or if additional claim information is needed.
8.Whether the claim involves "medical only"care or involves "lost days"from work,TPA will determine
which adjuster is specifically assigned to administer the claim.
H.Departmental Claims Administration
1.The Department has a right to monitor and control the time an injured employee is away from their
job because of workers'compensation related medical care,such as routine doctor visits or physical
therapy.The scheduling of medical appointments during work hours should be made while
considering medical necessity and also to ensure a minimal disruption to departmental operations.
The employee should be expected to return from a medical appointment within a reasonable time
frame or otherwise explain any excessive delays.If available,employees may schedule
appointments after their normal work hours.
2.The Department will maintain routine contact with an employee who is unable to work because of
an on-the-job injury.Not only is such a practice appropriate in an employer/employee relationship,
but this will allow Management the opportunity to identify claim related concerns or problems of the
employee.
3.The Department will obtain from the injured employee documentation which evidences the reason
for any medical related absences from work (physical therapy,doctor appointments)and/or the
current medical status (light duty restrictions,a release to full duty,unable to return to work).Such
documentation immediately must be forwarded to Risk Management.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 5 of 15
4.The Department will advise Risk Management of any discrepancies or delays in benefits being
provided to an injured employee.
5.Other City policies related to workers'compensation claims administration are Per-7,Temporary
Disability/Light Duty,and Personnel Policy Manual,Section 12.1,"On the Job Injury".
6.The employee is required to report to the department on their work status immediately after any
medical care,including the physician's written verification of that status.
I.Risk Management Claims Administration
1.Risk Management will coordinate and manage activities related to the overall claims'administration
process,especially involving correspondence and contact with TPA.
2.Risk Management will become directly involved with a department in the administration of a specific
claim whenever a claim is identified as presenting a problem or concern relative to servicing
agencies or medical providers.If the claim presents a complex medical situation or the claim has
a large loss potential,Risk Management will also become involved.The Department will be
responsible to notify Risk Management whenever any such specific assistance is required.
J.Return to Work Goal
1.While an employee is unable to work because of an on-the-job injury,the Department will maintain
contact with the employee to show their concern with the employee's wellbeing and to identify any
problems or questions,thereby minimizing the employee's frustration.
2.The goal of all parties is to return the employee to work;preferably full duty,otherwise restricted
duty as soon as the employee is considered medically able.
3.If an employee has been released to return to work with restrictions,the Department should make
every effort to accommodate the employee,either within their own DepartmenUDivision or formally
request Human Resources to seek temporary,restricted work assignment within another
Department.The employee's Department would still be charged with the employee's wages.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 6 of 15
Attachment A
FIRST REPORT OF INJURY OR ILLNESS
FLORIDA DEPARTMENT OFFINANCIAL SERVICES
DIVISION OF WORKERS'COMPENSATION
rsurtaneze +-c0-32-1741
errt yourcs EAce
wtcENvEDs MrroeCw arE scw «ECErvEDATELA-+Lu#;£nT
MtestMede Lao bot hart Muter 1---.--1 ~-,---
L!w»I +
Mt AD£e.£YEE¥egc AcIDEN"Itscauseat in
at/tt
ca -awl
Tr+«o art toothr
QCCPATon MM.aW+OLEstTAIOCC.ED airr goo+aFETE
atorwr 1Iha n ..IT
cows na CityofDelrayBeach FEDEPALIDLASER(FE NO ATEFR RPOEO/'Motor·an
0A 59-6000308.TS Beu»ets OuYeeet.#.etK10NwtsAvenue.-a,Delrayeach et FL 2,33444 Government SIF-Self insured
TEEN-Ne iL.ta Murr ATEE»Lorr au o DA,TEOF Ju
.."o □+£D Mo
LATATE EMO'YEE WEDO wL YuCC»TIuETOVA4rwa.OE He1Ea!otorsLo.A taatoRssaamt wwo#Ee:Coe □vEe•ahotostrI•2 Ag Darwaatwit4b negEADO
ca ta wot».neca
ocATowe pta@et.a.ial.h a.a."a
DATEDAT(tpp4ti aTE Par □+t □""ACE OF ACCENTetc th»2p
.".o ¥Pe □1-a 110
l oEt biloh zea-est.relcmtea-ethorned ----ta·Es D NO atf toe ea ----cu»uTYorACCENT -tatape we
22::::.7:::::7::::.z2°Mt.,A.Eii ATELEPE
pg.Awl OorAr
tnet.arid redacned.the.teenet.
so.or#arr 55 6w«.I
t
4a E
I rwroessarae r LT D s+awrosf]ff
D 1a)Deedse--t2 Mcearenas rstea 13 Mecatenvywechtecare et Tmesecreteau neared mtorst na3)
D tt igemrty myDeream:e-D-t2 Note atDerigtac/ea Ercyeegg"pay stgssoy .ho
Ertyz o wedgegg"gygtDzgttty h
□3 Lot TmeCe·tttgayctssnty Futsreuoco ?[YE3 if3gryEmDse
Date FrtPyrent iea d l AW a Rate
□T.T.D TT-0 D T.P □1B □PT.D DEATH D SETTLEMENT ONLY
ersty mount sdi payment interetecount Psdn +gyrent$
teMA.es NuttMat City otDelrayBeach
cLAnws-+tLNg±»Ir aunt..aooREs 4 TELgPt -veuts COa a £OEEiCLAaCODEI°""""'EW8NAC><C00E Pref.GovernmentalClaimSotons9194POBx958458
sEFWCECOTPAEa cLAM-+nu.mgnwr£e LakeMary,FL 32795-8456
6239 Tel:(800)237-8617
Fa(321)832-1448
natl/W..(gt7d3kt.-Z AC
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 7 of 15
City of Delray Beach
Attachment B
Where to charge workers'compensation claims.
Department coding required on states "First Report of Injury or Illness",Line "OBA"
00-General City Administration 01
Finance 02
Community Improvement 03
Planning &Zoning 04
City Clerk 05
Human Resources 06
City Attorney 07
City Commission 08
10-Environmental Services Administration 11
Engineering 12
Water/Sewer 13
Water Treatment 14
Utility Maintenance 15
Construction 16
20-Public Works Administration 21
Streets &Traffic 22
Fleet Maintenance 23
Building Maintenance 24
30-Police Department Administration 31
Training 32
Field Operations 33
Office 34
40-Fire Department Administration 41
Training 42
Field Operations 43
Office 44
SO-Parks &Recreation Administration 51
Parks Maintenance 52
Recreation 53
Beach Operations 54
Marina 55
NOTE:The "Administration"code generally is reserved for general liability-type claims.Parks &Recreation,Environmental
Services and Public Works may need to use the "Administrative"code for workers'compensation claims of administrative staff.
Please note that Police and Fire are specifically provided an "Office"code for such claims.
Workers'Compensation Claims Administration
RM-1O,Rev.6
Page 8 of 15
Attachment C
City of Delray Beach
Workers'Compensation
ACCIDENT INVESTIGATION REPORT
Note:Supervisor must fill out this report completely within 48 hours.Failure to provide accurate and complete information
may result in this report being returned to the applicable Supervisor (through his/her Department Head)for proper completion.
This report must be completed and signed/dated by the applicable Supervisor within the second full workday following the
accident;reviewed and signed/dated by the applicable Division Head and Department Head within the second full workday;
and,received by the Risk Manager and the Safety Coordinator within the third full workday.
1.Employee's Name:2.Job Title:3.Dept./Div.Code:
4.Accident Date:5.Time:6.Date accident reported to
supervisor:
7.Accident Location:
8.How did the accident happen?Describe:the specific job being done by the employee;and,what occurred to trigger
the accident.Use the reverse side ofthis report for additional comments,if needed.
9.What unsafe condition(s)of machinery,tools,10.What unsafe act(s)by the employee directly
equipment or the work area directly caused or caused or contributed to the accident?
contributed to the accident?Check all that apply:Check all that apply:
()1.None ()1.None
()2.Defective machinery,tools or equipment ()2.Failed to follow safety procedures/rules
()3.Inadequate machine or power tool guarding ()3.Failed to make equipment/material secure
()4.Inadequate safety devices ()4.Failed to warn or signal
()5.Fire or explosion hazards ()5.Failed to follow supervisor's instructions
()6.Unguarded floor openings ()6.Did not use proper personal safety equipment
()7.Unprotected excavations ()7.Used improper or defective tools/equipment
()8.Improper housekeeping ()8.Used tools or equipment improperly
()9.Tripping/slipping/protruding hazards ()9.Took unsafe position
()10.Inadequate illumination or ventilation ()10.Used improper lifting techniques
()11.High noise levels ()11.Operated at unsafe speed
()12.Causes other than above ()12.Causes other than above
Describe:Describe:
11.What directly caused or contributed to the above noted 12.What directly caused or contributed to the above noted
unsafe condition(s)?Check all that apply.unsafe act(s)?Check all that apply.
()1.Defective via normal use ()1.Unaware of hazards
()2.Defective via abuse/misuse ()2.Unaware ofsafety procedures/rules
()3.Faulty design ()3.Low level job skill
()4.Faulty construction ()4.Ignored known hazards
()5.Preventive maintenance failure ()5.Tried to save time
()6.Safety inspection failure ()6.Tried to avoid effort
()7.Caused by employee ()7.Tried to avoid discomfort
()8.Caused by other employee(s)()8.Illness/fatigue influenced action
()9.Housekeeping procedure deficiency ()9.Suspected drug/alcohol use
()10.Improper job planning.()10.Defective hearing/vision
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 9 of 15
13.What corrective actions have been taken (x)or will be taken (o)to prevent recurrence?Mark all that apply:
)1.Reinstruct employee(s)involved
)2.Discipline employee(s)involved
)3.Preventive reinstruction ofother employee(s)
)4.Job reassignment of employee(s)
)5.Improve inspection procedure
)6.Improve housekeeping procedure
)7.Improve preventive maintenance procedure
)8.Improve illumination
)9.Improve ventilation
)10.Install safety guards/devices
)11.Provide personal protective equipment
)12.Repair/replace tools and/or equipment
)13.Use safer materials
)14.Perform job safety analysis
)15.Establish safety procedures/rules
)16.Correction other than above
Describe:
14.Describe details of corrective action(s)taken or planned.
15.Who is responsible for corrective action(s)?
16.Approximate time frame for corrective action(s)to be implemented?
17.Names of witnesses,ifany?Ifwitnesses are other than City employees,addresses and phone numbers are required.
18.Additional comments:
19.Type of medical care provided:
First Aid ;Doctor ;Hospital.Will employee miss time from work?
Investigated by (Supervisor's signature/date):_
Reviewed by (Division Head's signature/date):_
Reviewed by (Department Head's signature/date):_
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 10 of 15
Attachment D
Memo
To:
[Mamre of Erioyee)
From:
{Administrative Aristan)
Date:
Re:Requestfor Supplemental Pay during Workers'Compensation Absence
Date of Accident;
In accordance with City Personnel Policy Section 12.1 [On the Job Injury}or unon contract,as applicable to you,employees who are
absent from duty because of a work related illness or injury can have their workers compensation wages supplemented by the Cty
during a period of ninety (90)days consecutive calendar days.This 9oday benefit"allow youto maintain your fuil,current City wages.
TheState's workers'compensation law does not provideworkers'compensation wages for certain absences (routine"doctor or therapy
visits,the frst 7 days of workers'compensation absences}.Therefore,you would not receive any income during such absences unless
the 90-day benefit period was in effect,or unless you usesick leave orvacation time.
The purposeof ths memo is to allow you to initiateor defer the start of the 90-day benefit period
EMPLOYEE REQUEST FOR SUPPLEMENTAL PAY
Please check below the payment option for your workers compensation absence(s).
[g 1elect to iutgte the 9o-day benefit period to supplement my income during my workers'compensation absences so as to
maintain my full current City wages.I understand that one my 90day benefit period ends,my only income during workers'
compensation absences will be workers compensation wages /if the law requires payment)unless I use sick leave or vacation
timeto supplement such wages
I agree that in consideration for receiving my regular paycheck(s)from the city during this period,I will endorse workers'
compensation checks back to theCity
I request the 9o consecutive calendar days to benon
[]1elect to deterthego-day benefrt period at this tme understand that unless !use sick leave or vacaton time to supplement
myworkers'compensation wages for absences,this election will result in pay that is less than my full current City wages
I also understand that I mnay electto initiate the 90-day beneft period at a later date by completing another Request'memo.
PLEASE NOTE You must return this form to my attention no later than the Friday preceding payday to assure your paycheck accurately
reflects your above election.if you tail_to_return_thus_form as requested,the City will presume you have elected to initiate the 90-day
benefit period to begn from the date of your accodent
Employee's 5gnature
Signed Copy Distribution
IOriginal Department File
cc.Employee
Risk Management
Payroll Administrator
ape
To be completed by Administrative Assistant if employee elects 90-day benefit period:
Supplemental pay will be paid through.
RM-10Artac+rem D
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 11 of 15
Attachment E
WORKERS'COMPENSATION CLAIMS
PAY CODES
WITHIN THE 90-DAY BENEFIT PERIOD:
RG "Regular Earnings"paid;employee at work;workers'comp wages not paid.
IA "Injury Appointment";regular earnings paid for partial workday absence,e.g.,doctor
or physical therapy visit;workers'comp wages not paid.
17 "Initial 7 day absence";regular earnings paid for full day absence;workers'comp
wages paid but only retrospectively if more than 21 total days of authorized absence;
workers'comp wages paid but claimant endorses check to City.
IP "Injury Pay";regular earnings paid for full day absence;workers'comp wages paid
but claimant endorses check to City.
OUTSIDE THE 90-DAY BENEFIT PERIOD (BENEFIT NOT ELECTED OR 90 DAYS HAVE EXPIRED):
RG "Regular Earnings"paid;employee at work;workers'comp wages not paid.
AP "Absence Pay";regular earnings not paid;partial workday absence,e.g.,doctor or
physical therapy visit,but only on the date-of accident;workers'comp wages not
paid.
LW "Leave without Pay;regular earnings not paid;partial workday absence,e.g.,doctor
or physical therapy visit,while employee is scheduled to work;workers'comp wages
not paid.
WC "Regular Earnings"not paid;full day absence;only workers'comp wages paid.
SP "Sick Pay";supplements workers'comp wages if elected.
VP "Vacation Pay";supplements workers'comp wages if elected.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 12 of 15
Attachment F
City of Delray Beach
MEDICAL CARE &WORK AUTHORIZATION
FLORIDA WORKERS'COMPENSATION
Claims Administrator
PGCS
PO BOx 958456
Lake Mary,FL 32795-3456
800-237-5617
EMPLOYEE
EMPLOYER:Citv of Delrav Beach DEPARTMENT:
GENERALJOB DESCRIPTION:
DATE OF INJURY:DESCRIBE INJURY:
SIGNATURE OF CITY REPRESENTATIVE:
PHYSICIAN:PLEASE COMPLETE AND RETURN TO EMPLOYEE
powee re:port 'eor by a
equivalent form providedby ptyan,zurch a:s cosy o the State DWC-25)totheir supervisor asoon a practical or st eartmru call theirsupervisor if
unable topersonally visit theirwor pace Inall cae:,this formmuzereturnedto the :upervaor beforeaworkanbe age
RM-10 Meda/Reieaze form Attachment f
FACILITY/HOSPITAL NAME.
NAME OF PHYSICIAN (Please Print).
DATE AND TIME OF SERVICE:
DIAGNOSIS:·-
TREATMENT RENDERED/ORDERED:
REMARKS BY PHYSICIAN (OPTIONAL):
EMPLOYEE WORK STATUS:
REGULAR WORK;NO WORK;RESTRICTED WORK (LIST RESTRICTIONS):
DATE EMPLOYEE MAY RETURN TO WORK.OR L_)UNDETERMINED
EMPLOYEE MME:9;OR,L_)EMPLOYEE NOT A MMI
DATE OF NEXT APPOINTMENT:TIME:
SIGNATURE OF PHYSICIAN-We»
Te em is tie tor r for work a:ziu:nrert as instructed the above tr:ician.Employee mart retum this orgns f o rm (or oth er
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 13 of 15
Attachment G
INITIAL NOTICE OF w/c INJURY
Date ofAccident:
Time ofAccident:.
Name ofInjured Employee.
Home Address:
Home Telephone:
Date of Hire:
Hourly Rate.
Department Division Code:-
Description ofAccident:
Part of Body Affected:
Initial Care Provided by.
DepartmentContact for Additional
Information.
This will serve as receipt/acknowledgement of the Initial Notice of Workers'Compensation Injury or
exposure form by the Risk Management Division.We will retain the same for our records.Please note.
you may seek authorization from the date of injury to acquire medical treatment with our in-network
provider,Concentra located at 141 NW 2O"Street,Boca Raton,FL 33432.The telephone number is
561-368-6920.The hours ofoperation are Monday -Friday from 8am to 6pm and Saturday from 8am
to 12pm.
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 14 of 15
Attachment H
WAGE STATEMENT E-MAIL ATTACHMENT
Name of Injured Employee.
Date of Accident.
Pease type the information to the nght of each item in RED on this e-mail and return to me within 3
business days of the date of this e-mail.
Customary Work Week (exampie.Monday -Fnday)-
Customary Days Worked/Week (example.5 days/week)-
Customary tours WorkedWeek (example 40 hours/week)-
Hours worked each day for the following partial pay periods.Include any OT or other special pay and
rate of pay if different from base hourly rate.
Day Pay Period Hours Worked Over-time
Saturdav
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
9M-104rzacnrert H
Workers'Compensation Claims Administration
RM-10,Rev.6
Page 15 of 15
Attachment I
¢oo
my llatrxx
good medicine for business
Preferred Governmental Claims Solutions
Workers'Compensation Prescription Information
PGCS Employer:
Please fill out employee information below and provide employee with this document to take to any
pharmacy with prescriptions.
Employee Name:
Group #:10602193
Member ID (SSN):
Date of Injury:
Processor:myMatrixx
Bin#:014211
Day supply is limited to 3 days for a new injury.
myMatrio Help Desk:(877)804-4900
I Employer
Signature.
I Phone:[as
PGCS Employee:
Preferred Governmental Claims Solutions has partnered with myMatrixo to make fling workers'compensation
prescriptionseasy.
This document serves as a temporary prescription card.A permanent prescription card specific to your injury will be
forwarded directly to you within the next 3 to 5 business days
Please take this letter and your prescription(s)to a pharmacy near you myMatrixx has a network of over 60,000
pharmacies nationwide.If you need assistance locating a network pharmacy near you,please call myMatrotoll free at
(877)804-4900.
IF YOU ARE DENIED MEDICATION(S)AT THE PARMACY PLEASE CALL (877)804-4900
Pharmacist:.Please obtain above information from the injured employeeif not already filled in by employerto process
prescriptionsfor theworkers'compensation injury only.Document onlyvalid if signed and dated by employer above.
For questions or rejections please call (877)804-4900 Pleasedo not send patient home or have patient pay for
medication(s)beforecalling myMatrix forassistance.
NTE:Certain medications are pre-approved for this patient;these medicationswill process without an authorization.
All others will require prior approval.
FOR ALL REJECTIONS OR QUESTIONS CALL (877)804-4900