|
FORM C -Workers' Compensation Claim Form
<br /> Workers'Compensation Claim Form(DWC 1)&Notice of Potential Eligibility 4
<br /> Formuimio de Recl®no de Compensacl6n de TrabgJadores(DWC 1)y No*J wOn de Poslble Elrglbl Uad
<br /> Ifyou are injured orbecomeill,either physically or mentally,becauseofyourhob, St Ud se lesions o se enferma,ya sea fisrramete o meualmente,debido a su
<br /> including injures resulting from a workplace crime,you may be entitled to trabajo,incluyendo lesions que resulten de un crimen en el lugar de trabsjo,es
<br /> workers' compensation benefits. Use the attached form to file a workers' posible que Ud tenga derecho a benefiaos de compensaci6n de trabajadores.
<br /> compensation claim with your employer.You should read all ofthe information Utilice el fornulano adjunto pars presentar un reclamo de compensation de
<br /> below.Keep this sheet and all other papers for your records.You may be eligible trabajadores con su enpleador. Ud. debe leer toda Is loformadon a
<br /> for some or all of the benefits listed depending on the nature of your claim If you cmtinuaci(n.Narde esta hoja y todos los dams doamentos para sus archivos.
<br /> file a claim,the claims administrator,who is responsible forhandling your claim, Es posible que usted rains los requisitos pars todos los beneficios,o parte de
<br /> trust notify you within 14 days whether your claim is accepted or whether estos,que se enumeran dependiendo de Is indole de su reclamo.Si usted presents
<br /> additional investigation is needed. un reclamo,I administrador de reclamos,quien es respcnsable por el manejo de su
<br /> To file a claim,complete the"Employed'section of the fart,keep one copy and reclano,debe notificarle dentro de 14 dfas si se acepta su reclamo o si se necesita
<br /> give the rest to your employer.Do this right away to avoid problems with your i nvesttgaci6n adicional.
<br /> claim.In some cases,benefits will not start until you inform your employer about Para preseuar un reclamo, flene Is secci6n del fcrnulario designada pars el
<br /> your injury by filing a claim form Describe you injury conpletely.Include every "Fmpleado,"guarde una copra,y dele el resto a sic empleadcr.Hags esto de
<br /> part of your body affected by the injury.If you mail the form to you employer, mmednato para evntar problemas con su reclamo. En algunos casos,los beneficios
<br /> use first-class or certified mail.If you buy a return receipt,you will be able to no se iniciarbn hasta que usted le inforne a su empleador acerca de su lesi6n
<br /> prove that the claim fora was nailed and when it was delivered.Within one mediante Is presentaci6n de un formlario de reclamo. Desmba su lesidn por
<br /> working day after you file the claim form,your employer must complete the con-pleto.Incluya cada parte de su anepo afectada por Is lesi6n Si usted le envia
<br /> "Employe"section,give you a dated copy,keep one copy,and send one to the por correo el fonulano a su enpleador,utilice primers clase o correo cetificado.
<br /> claims administrator. Si usted conprs un acuse de recibo,usted podri demcetrar que el formulario de
<br /> reclamo fue anviado por correo y arando fue entregado Dertro de un dia laboral
<br /> Medical Car c Your claims administrator will pay for all reasonable and despues de presenfar el fimnulario de reclamo,su empleador debe completer Is
<br /> necessary medical care for your work injury or illness.Medical benefits are recci6n designadapara el"Empleador,"le dara a Ud una copia fechada,guardarA
<br /> subject to approval and may include treatment by a doctor,hospital services, unis oopia,y enviarn una at administrador de reclamos.
<br /> physical therapy,lab tests,x-rays,medicines,equipment and travel costs.Your
<br /> claims admintstator will pay the cads of approved medical services directly so Atencidn Medics: Su administiador de reclemos pagarA por Wde la etenci6n
<br /> you should never see a bill.There are limits on chiropractic,physical therapy,and maca razonable y necesana para su lesi6n o enfemedad relacionada con el
<br /> other occupational therapy visits. trabajo Los beneficros medicos estin suietos a Is aprobac16n y pueden incluir
<br /> tr atamiento por parte de un medico,los servicios de hospital,Is terapia fisics,los
<br /> The Primmy Treating Physician (PTP) is the doctor with the overall anglisis de laboratoio,las medicinas,equipos y gastos de viaje Su administrador
<br /> responsibility for treatment of your injury or illness de reclaims pagari directamente los costos de los sevicios medicos aprobados de
<br /> • If you previously designated your personal physician or a medical group, manse que usted nunca verb una factors.Hay unites en terapia quiroprectica,
<br /> you may see your personal physician or the medical group after you are
<br /> injured fisica y otras visitas de terapia ocupacional.
<br /> • If you employer is using a medical provider network(1vW or Health Care El Medico Primario sue le Athende(Prbna"Treadnk PBnslrlax-PTP)es el
<br /> Organization(HCO),in most cases,you will be treated in the MPN or HCO medico con Is responsabilidad total pars tratsr su lesi6n o enfemedad
<br /> unless you predesignated you personal physician or a medical group.An • Si usted desgn6 previamante a sic medico personal o a un grupo medico,
<br /> MPN is a group of health rare providers who provide treatment to wakes usted podrA ver a su medico personal o grupo medico despues de lesionarse
<br /> injured on the job.You should receive information from you employer of • Si su empleador esU utilizando una red de proveedores medicos(Medicd
<br /> you are covered by an HCO or a MPN.Contact your employe for more Prmider Nanr+ork MPNJ o una Organuandn de Cuidado Medico(Health
<br /> information.
<br /> • If your employer is not using an MPN or HCO,in most cases,the claims Care Oro HCO
<br /> m nos q en t mayorfa de nos casos,pred sere su m6o en
<br /> administrator can choose the doctor who first treats you unless you Is MPNo HCO a coerce que used hizo una designaci6n previa de sic medico
<br /> predestgnated you personal physician or amedical group persoricl o grupo medico. Una MPN es un grupo de proveedores de
<br /> • If your employer has not put up a poster describing your nghts to workers' asistencia medica quien da trataniento a los trabajadores lesionados en el
<br /> compensation,you nosy be able to be treated by your personal physician trabajo. Usted debe recibir inforrmci6n de su enpleador si su tratamiento es
<br /> right after you are injured. cubierto por una HCO o uns MPN Hable con su empleador pera mils
<br /> Within one working day after you file a claim form,your employer or the claims mformacn6n
<br /> administrator must authorize up to$10,000 in treatment foryour injury,consistent Si su empleador no estfl utilizando una MPN o HCO,en Is maycrfa de los
<br /> with the applicable treating guidelines until the claim is accepted or rejected.If casos,el administrador de reclamos puede elegir el medico que to atiende
<br /> the employer or claims administrator does not authorize treatment right away,talk pnmero a menos de que usted hizo una designaci6n previa de sic medico
<br /> to your supervisor,someone else in management,or the claims administrator.Ask personal o grupo medico.
<br /> for treatment to be authorized nght now,while waiting for a decision on your ' Si su er pleador no ha colocado un cartel desmbiendo sus derechos pare Is
<br /> claim If the employer or claims administrator will not authorize treatment,use compensation de trabajadores,Ud puede ser tratado por su m6dieo personal
<br /> inmediatamente despue_s de lesionarse.
<br /> your own health insurance to get medical care. Yea health cosier will seek
<br /> reirrbursement from the claims administrator.If you do nothave health insurance, Dntro de un dia labcral despues de que Ud.Presents un formulano de reciamo,
<br /> there are doctors, clinics or hospitals that will treat you without irranediate su empleador o el administrador de reclamos debe autorizar hasty$10000 en
<br /> payment.They will seek rembursenent from the claims administrator tratarmento pare su lesi6n,de aaherdo con las pautas de trataniento aplicables,
<br /> pasta que el reclamo sea aceptado o rechazado St el empleador o administrador
<br /> Switching to a Different Doctor as Your PTP: de reclamos no autcriza el tratamierto de inmediato,hable con su supervisor,
<br /> • If you are being treated in a Medical Provider Network(MPN),you may alguien mis en Is gerencia,o con el administrador de reclamos. Pida que el
<br /> switch to other doctors within the MPN after the fist v isit
<br /> • If you are being treated in a Health Care Organization(EICO),you may tratamnento sea autaizado ya mismo,mientras espera una decisi6n sobre sic
<br /> switch at least one time to another doctor within the HCO.You may switch rec
<br /> doctorlamo. Si el errpleadcr o administrador de reclamos no anucriza el tratamiento,
<br /> to a doctor outside the HCO 90 or 180 days after your injury is reported to utilice su propio seguro medico para recnbir atenci6n medics Su cor pa(iia de
<br /> your employer (depending on whether you are covered by employer- seguro medico buscari reembolso del administrador de reclamm Si usted no
<br /> provided health insurance). tiene seguro medico,hay m6dicos,clinicas u hospitales que to tratarin sin pago
<br /> • If you are not being treated in an 1APN or HCO and did not predesignate, innediato Ellos buscuirn reembolso del adnimstradcr de reclamos.
<br /> you may switch to a new doctor one time during the first 30 days after your
<br /> injury is reported to your employer Contact the claims administrator to Cambtando a nxro Medico Primario o PTP.
<br /> switch doctors.After 30 days,you may switch to a doctor of your choice if • Si usted esti recibiendo tratamiento an una Red de Proveedores M6dicos
<br /> Rev.1112016 Page 1 of 3
<br /> San Joaquin County
<br /> Department of Public Works
<br /> County of San Joaquin Dept of Public Works IIPP Rev 2020-01-31.docx P a g e 24
<br />
|