Reporting an Accident/Injury

  1. Accident/Injury Occurs
  2. Employee Reports Accident/Injury to Supervisor/HR
  3. If Accident/Injury is life threatening, Supervisor calls 911 or sends employee to the nearest hospital.
  4. If Accident/Injury requires immediate medical attention (not life threatening) and request medical treatment, Supervisor sends employee to the applicable urgent care clinic below.
  5. If employee is sent for medical treatment, Supervisor supplies employee with the Introductory Letter to Physician.
  6. Letter includes instructions on post-accident drug screening. This must be done within 24 hours of an accident/injury.
  7. If employee declines medical treatment, supervisor makes sure that this is indicated on the paperwork.
  8. Supervisor Collects the following paperwork and sends to HR
  9. First Report of Injury – Completed by Supervisor/Employee
  10. Supervisor’s Report of Injury – Completed by Supervisor
  11. Employee’s Report of Injury – Completed by Employee
  12. Provide any witness statements
  13. HR files claim with Worker’s Compensation Insurance Carrier.
  14. W/C Insurance company will continue to stay in touch with HR and Injured Employee

Office/Store, 83, 134 (Cocoa)
Medfast Urgent Care Centers LLC
5005 Port St John Pkwy
Cocoa, FL 32927
(321) 633-8620 / Store 127 (Waldo)
CareSpot Express Healthcare
720 SW 2nd Ave Ste 160A
Gainesville, FL 32601
(352) 240-8000 / Store 12 (Yeehaw Junction)
Urgent Care West
2050 40th Ave Ste 6
Vero Beach, FL 32960
(772) 564-0175
Best Western Hotel & Store 24 (Titusville)
Medfast Urgent Care Centers LLC
5005 Port St John Pkwy
Cocoa, FL 32927
(321) 633-8620 / Store 392 (Fernandina Beach)
Amelia Urgent Care LLC
96279 Brady Point Rd
Fernandina Beach, FL 32034
(904) 321-0088 / Store 50 and 52DQ (Fellsmere)
Indian River Health Services Inc
801 Wellness Way Ste 107
Sebastian, FL 32958
(772) 226-4200
Store 11 and 91DQ (Saint Augustine)
Healing Arts Urgent Care
120 Health Park Blvd Ste 1
Saint Augustine, FL 32086
(904) 823-3401 / Store 350 (Orlando)
Florida Hospital Central Care
12500 S Apopka Vineland Rd
Orlando, FL 32821
(407) 934-2273 / Store 57 (Flagler Beach)
Florida Hospital Central Care
1270 Palm Coast Pkwy NW
Palm Coast, FL 32137
(386) 225-4631
Store 296 (Davenport)
Legends Family Medical Center
1485 Legends Blvd
Champions Gate, FL 33896
(407) 390-6480 / Store 401 (Winter Haven)
First Help Urgent Care Clinic
320 1st St S
Winter Haven, FL 33880
(863) 299-8485 / Store 345 (Sanford)
Florida Hospital Central Care
4451 W. State Road 46
Sanford, FL 32771
(407) 330-3412

First Report of Accident/Injury

Supervisor's Report of Accident/Injury

Employer
M&R Enterprises of Brevard / Injured Employee’s Name
/ Injury Date
Location of Accident
/ Injury Time
am pm / Shift Start Time
am pm
Manager/Supervisor / Employee’s Job Title
Rate of Pay
hrwk / Number of hours work per day / Number of days work per week
Where and how did the accident happen?
What were you doing at the time of the accident?
Specify equipment, substance or object connected with accident?
Nature of Injury (Scratch, cut, bruise, etc.)
Part of Body Injured (Left Ring Finger, Right Ankle, etc.)
Were there any witnesses? (See attached witness statements)
Yes No; If yes, Names:
Employee was Referred to:
Accident Resulted In:
Injury Illness Property Damage Near Miss
First Aid Medical Clinic Treatment Lost Time No Injury/Illness
Employee was Referred to:
Measures recommended to prevent a similar accident:
Did Employee Return to Work?
Yes No / Date Returned to Work: / Time Returned to Work:
ampm
Supervisor/Manager Signature: / Date:

First Report of Accident/Injury

Employee's Report of Accident/Injury

Employer
M&R Enterprises of Brevard / Injured Employee’s Name / Injury Date
Location of Accident
/ Injury Time
am pm / Shift Start Time
am pm
Hire Date / Requesting Medical Treatment?
Yes No / Job Title
Employee Address / City / State / Zip
Date of Birth / SSN / Gender
MaleFemale
Where and how did the accident happen?
What were you doing at the time of the accident?
Specify equipment, substance or object connected with accident?
Nature of Injury (Scratch, cut, bruise, etc.)
Part of Body Injured (Left Ring Finger, Right Ankle, etc.)
Were there any witnesses? (See attached witness statements)
Yes No; If yes, Names:
Employee was Referred to:
Did you return to work?
Yes No / Date Returned to Work: / Time Returned to Work:
ampm
Accident Resulted In:
Injury Illness Property Damage Near Miss
First Aid Medical Clinic Treatment Lost Time No Injury/Illness
Employee Signature: / Date:

Introductory Letter to Physician

AmeriSys/Coventry Network

Date:

Employer Name: M&R Enterprises of Brevard, Inc.

Employer Telephone Number: (321) 631-0245, extension 116

Dear Dr.:

Employee Name is scheduled for an initial visit as an employee of M&R Enterprises of Brevard, Inc. which is a participant in the FHM Insurance Company/AmeriSys/Coventry Network. This letter does not confirm that the injury or condition is covered by Worker’s Compensation Insurance. That determination will be made as soon as an investigation is completed by our claims administrator, USIS.

DRUG TESTING IS REQUIRED: Urinalysis

Breathalyzer (blood test if necessary)

We are working closely with AmeriSys/Coventry Network and the involved medical providers to ensure that our employees receive access to timely and medically necessary treatment for their industrial injuries. In the best interest of our employees, we will have modified work available, which would allow the employee to return to work at the earliest possible date. Please keep this in mind as you treat this employee.

PLEASE CONACT UTILIZATION MANAGEMENT

AT 888-346-3461 Ext. 3131

WHEN ONE OF THE FOLLOWING OCCURS:

  1. New Injury with Disability > 7 Days & No Release to Return to Work
  2. Hospitalization
  3. Anticipated Surgery
  4. Physical Therapy or Chiropractic Treatment Recommended
  5. Referral to Provider
  6. Assistance Required to Return Injured Employee to Work
  7. Repeat Major Diagnostic Studies

All claims for treatment must be submitted to the address below on an HCFA 1500, UB 92 or the appropriate form required by the state. Please submit all medical reports within the time frame required by the applicable state law.

FHM Insurance Company

P.O. Box 616648, Orlando, FL 32861-6648

407-351-1212/888-346-3461- Ext 6353; FAX: 407-352-5788

Should you have any questions regarding your participation in the Coventry Network, please call 800-342-5888 or 800-937-6824.

Sincerely,

Chrissy Council, HR Manager

Updated: 5/10/2017