CLAIMS

Claim Forms


Revised to include Prescription First Fill Form:
Complete Claim Form Packet
(can be printed 1 or 2 sided)

Beginning 12/1/15, injured employees will take the Prescription First Fill form to a network pharmacy to receive initial prescription medication at no cost to the employee or policyholder.

Or print specific parts of the Claims Packet:

English Forms

Authorization for Initial Treatment (English)
Completed and signed by manager. Send this form with injured employee to your medical provider.

HIPAA Authorization for Release of Health Information (English)
Signed by employee. Send this form with injured employee to your medical provider.

Prescription First Fill Form (English)
Completed by manager. Send this form with injured employee to your medical provider.

Physician’s Report of Employee Injury
Send this form with injured employee to your medical provider to be completed by the physician.

Employee Accident Report (English)
Injured employees will complete this form in the event of an employee accident.

Supervisor’s Report of Accident (English)
To be completed by the supervisor on duty at the time the accident occurred.

Witness Statement (English)
To be completed by the witness.

MCD Accident Report (English)
To be completed by a manager or the owner when submitting a claim for reimbursement.