•  
     
    PENNSYLVANIA CLAIMS REPORTING:

    EMPLOYER CHECKLIST

     
    • WHAT TO DO WHEN AN INJURY OCCURS:
       
      •  In an emergency, take your injured employee to the
      nearest emergency facility.
      •  For all work-related injuries, provide the list of panel
      physicians to the injured employee.
    •  
      Please refer to the Flow Chart for specific directions
    • Injury Report Form
      •  The injury report is the injured employee’s statement of what happened.
      • Have the injured employee complete this form and email the completed form
      • to the HR Office, kraynakl@hasdpa.net or strickenglossp@hasdpa.net
       
      • This form explains the employee’s rights under the Pennsylvania workers’

    compensation law that must be signed by the employee at the time of injury.                                  

    • Send this copy to the HR Office along with the Injury Report Form.
        
       Medical Authorization Form
      •  This form authorizes Eastern Alliance to request medical records

                   related to the injured employee's claim 

    Physicians Panel for work related injury physicians.
    Please contact a physician on this list to be evaluated.
     
    Accident Investigation Form needs completed by Supervisor with the
    injured employee to determine corrective actions to prevent future incidents.
    • If you have a Worker's Compensation claim, you will be receiving a KeyScripts
    • prescription card in the mail.  Utilize this card when filling your prescriptions.
    • If you need the prescription prior to receiving your card, go to the pharmacy
    • on the Keyscripts list, under the pharmacy information link above and have your
    • claim number and the toll free Keyscripts phone number, 1-866-446-2848.  
    • The pharmacist will be able to confirm the claim and fill the prescription.