Workers' Comp Internal Process

Below are listed the Responsible Parties and the Required Actions to take.

Injured Employee

1. Immediately report job-related injury or illness to supervisor and seek appropriate medical care.

   • Medical Care Choices - unless you have a pre-designated a personal physician, medical services for workplace injuries may be provided by the Humboldt Student Health Center during normal work hours and when semesters are in session.  

     If the Student Health Center is unavailable, please seek non-emergency medical attention at:

     Mad River Occupational Health Services
     3800 Janes Rd
     Arcata, CA 95521
     (707) 825-4907; or

     In the event of an emergency, please seek assistance at Mad River Community Hospital Emergency Room or the nearest hospital emergency room.

     For non-emergency care, employees must contact Mad River Occupational Health Services to provide medical treatment for the first 30 days from the date of injury. However, if prior to an injury, Human Resources has been provided with a Pre-Designation Form signed by a personal physician, employees may seek medical care from this physician immediately after injury. Under Labor Code Section 4600 (d) the designated physician must (1) be the employee's primary care physician, (2) have treated the employee in the past, (3) retain his or her medical records (including medical history), and (4) agree to be predesignated.

     Your primary treating physician (PTP) has overall responsibility for treating your injury or illness. The PTP directs your medical care within recommended guidelines established by law. The PTP is responsible for coordinating care between other medical providers. In more serious cases, the PTP will assess permanent disability, entitlement to vocational services, and need for future medical services. You may change your treating physician to another physician 30 days after the injury is reported. If you want to change your treating physician, contact your campus Benefits & Leaves Coordinator or Sedgwick CMS.

     You may pre-designate a personal physician to treat you in the event of a work-related injury. Your personal physician must be designated by you in writing prior to your injury or illness, must be a Medical Doctor, must be your primary care physician who has previously treated you in the past and maintains your medical records, and agree to accept Workers’ Compensation Insurance. Contact the Benefits & Leaves Coordinator for additional information about pre-injury physician designation.

2. Request and complete Employee's Claim for Workers' Compensation Benefits (DWC Form 1).
3. Return DWC Form 1 to Supervisor or to the Benefits & Leaves Coordinator, Student Business Services 353.

   • The Benefits & Leaves Coordinator will give you a completed and signed copy and send the remainder to Sedgwick CMS. State law requires employers to authorize medical treatment within one working day of receiving a claim form. Someone from Sedgwick CMS will be in touch with you to explain the benefits you will be receiving.

     Insure your right to benefits by immediately reporting every work-related injury or illness. Any delay in reporting may delay or bar your workers’ compensation benefits.

      

Supervisor

1. Arrange for appropriate medical care.

   • Transportation of Injured Employee -

     Due to liability reasons, neither supervisors or fellow employee should drive an injured employee to seek treatment. If the injury is an emergency, call 911 for an ambulance. For immediate non-emergencies where an employee is unable to drive themselves to seek treatment, Humboldt has an agreement with City Cab of Eureka. Humboldt will pay City Cab for rides both to and from treatment with authorization. Please use the following form for authorization:

     Authorization to Transport Form
     Request for Non-Emergency Medical Transportation for Work-Related Injuries

2. Complete required forms.  Employee should fill out the DWC-1 form.
   • Claim Form DWC1
     Employee’s Report of Injury (DWC-1) – Must be given to employee at the time injury is reported to Supervisor, or as soon as possible after medical treatment is received
   • Supervisor's Report of Injury
     Supervisor’s Report of Injury – MUST BE SUBMITTED TO HUMAN RESOURCES WITHIN 24 HOURS OF KNOWLEDGE OF INJURY
3. Fax both forms to Benefits & Leaves Coordinator within 24 hours of knowledge of injury
4. Notify employee about Return-to-Work Program, maintain contact and encourage early return to work.

5. Notify Benefits & Leaves Coordinator and departmental attendance clerk when employee misses work or returns to work.

    

Benefits & Leaves Coordinator

1. Complete Employer's Report for Occupational Injury or Illness (Form 5020) and send to the Third Party Administrator (TPA), along with copy of DWC Form 1 and STD 620.
2. Send copies of STD. 620 and DWC Form 1 to Environmental Health and Safety officer.
3. Return copy of DWC Form 1 to employee.
4. Send copy of Supervisor's Injury Prevention Report (STD 620) to supervisor.
5. Establish and maintain regular contact with TPA claims adjustor regarding status of claims.
6. Provide TPA with all documentation they may require to process claims. These include but are not limited to: first injury reports, doctor's statements, return to work statements, job descriptions, etc.

Environmental Health and Safety Officer

1. Investigate injury/illness if warranted, and report finding to department management and Human Resources.

Third Party Administrator (TPA)

1. Conduct further investigation to determine if work related.
2. Approve/deny claim.
3. Establish and maintain regular contact with Human Resources staff to process claims, IDL notifications and other responsibilities necessary to providing a comprehensive workers' compensation program.