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    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.
       
      •  The incident report is the injured employee’s statement of what happened. Have the injured employee 
      completethis form and keep a copy of this document for your records.  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 employees at the time of injury.
      •  This form also includes the list of panel physicians selected by the employer.
      •  Provide a signed copy of the forms to the injured employee and to the HR office.
       
       
      •  This form authorizes BrickStreet Insurance to request medical records related to the injured 
      employee's claim.
       
      •  Have the injured employee take this form to his/her treating physician, which will include any 
    • restrictions the employee may have.
    Physician Panel of work related injury physicians.  Please contact a physician on this list to be evaluated.
     
     
    • Instruct injured employee to utilize the First Fill Form toobtain prescriptions related to the work 
    • injury and prior to acceptance of the claim.
    • Instruct injured employee that upon acceptance of the claim, a medical identification card will be
    • mailed. This card should be presented to the pharmacy when having future work-related
    • prescriptions filled.