1. health and fitness
2. drugs

Sedgwick Claims Kit
Tennessee
P.O. Box 14779 | Lexington, KY 40512 | Toll Free: 866-738-9201 | Fax: 859-280-3275
Dear Insured:
We would like to welcome you as a policyholder of Southern Insurance Company.
Sedgwick is your Claims Administrator and we are pleased to be able to provide you
with workers’ compensation claims handling services. Please follow the below
instructions for filing a new claim and note the claim kit attachment.
Where do I report a claim?
 Phone:
 Email:
 Fax:
855-728-5277 (855-7ATLAS7)
[email protected]
866-383-3296
Where do I send my injured employee for medical treatment?
 Website:
www.sedgwickproviders.com/AG
Sedgwick Claim Kit Attachments:
•
•
•
•
•
•
•
•
A Beginners Guide to Tennessee Workers’ Compensation
Posting Notice – English & Spanish – MUST BE POSTED
Employer’s First Report of Injury or Illness (Form C-20)
Wage Statement (Form C-41)
Choice of Physician Agreement - English & Spanish (Form C-42)
Workers’ Compensation Authorization for Release of Medical - English &
Spanish (Form C-31)
Atlas General First Fill Temporary Pharmacy Card
Atlas General Pharmacy Card
Need a loss run?
 Email us:
[email protected]
Have more questions?
Contact the Atlas Customer Care Team @ Sedgwick - One of our friendly Client Services
Associates will be happy to assist you.
 Phone:
866-738-9201
 Email:
[email protected]
We appreciate your business and believe that communication is critical for successful
claims administration. We encourage you to contact us if you have any questions.
www.Atlas.us.com/claims
TENNESSEE Welcome Letter – Southern Insurance Co. 4/2014
A BEGINNER’S GUIDE TO
TENNESSEE WORKERS’ COMPENSATION
Basic facts about the Tennessee Workers’ Compensation System
For Dates of Injury on or after July 1, 2014
WHAT SHOULD AN EMPLOYEE DO IF INJURED AT WORK?
An employee should report a work-related injury to his/her supervisor within 30
days of the date of the injury or within 30 days of when a doctor first tells the
employee that his/her injury is work-related so that the proper forms and
paperwork can be completed.
Reporting your injury as soon as possible will speed up
the handling of your claim. All required forms should be completed by the employee’s supervisor.
Required forms are located on the Department of Labor and Workforce
Development’s website located at: http://www.tn.gov/labor-wfd/mainforms.html
If the injury requires emergency treatment, the injured
worker should be taken to the closest hospital
emergency room.
HOW IS A DOCTOR SELECTED?
A supervisor should provide an injured employee a panel of at least three
Need More
Help? nearby doctors willing to provide workers’ compensation medical treatment.
The supervisor should provide the panel of doctors on an “Agreement between
Employer/Employee Choice of Physician”, Form C-42. The employee must
select one doctor from the Form C-42 and sign the form. The doctor chosen
by the employee will become the authorized treating physician and will
provide medical treatment at the employer’s expense. If emergency treatment
is required, the supervisor should provide the panel after the injury is
stabilized.
Request and keep a copy of your signed form for your
records. If you do not sign the form, but accept
medical treatment from a doctor on the form, it may be
considered that you have chosen that doctor.
CAN AN EMPLOYEE BE FIRED
FOR REPORTING A WORK INJURY?
No, it is illegal for an employer to fire an employee for
reporting a work injury. If an injured employee is fired and
believes it was for reporting a work injury, the employee
may wish to consult an attorney.
The Workers’ Compensation Division does not have
authority to resolve wrongful termination claims.
The Ombudsman Program of the
Tennessee Division of Workers’
Compensation is available to assist
employees, employers and insurance
companies that do not have attorney
representation with any questions they
have. Information is available on the
Division’s website at:
www.tn.gov/labor-wfd/wcomp.html .
Assistance is also available by calling
1-800-332-COMP (2667).
HOW CAN AN INJURED WORKER
PROTECT HIS/HER RIGHTS?
The right to receive workers’ compensation benefits does
not stay open forever. To protect his/her rights, an injured
worker must file a Petition for Benefit Determination (PBD)
form. The form is available on the Division’s website. In
most cases, the deadline to file the form is one year from:
1. The date the injury occurred; or,
2. The date the last temporary disability benefits were
paid or medical benefits were provided for the
injury, whichever is latest.
WHAT BENEFITS ARE INJURED EMPLOYEES
ENTITLED TO RECEIVE?
Employees who have suffered a compensable injury,
meaning that the authorized treating physician has
determined it to be work-related, may be entitled to
receive the following:
Medical treatment, at no cost to the employee:
This treatment must be provided for as long as required by
the authorized treating physician. Medical treatment
recommended by the authorized treating physician that is
denied by the insurance company’s utilization review can
be submitted to the Division’s Utilization Review Program
for additional review and consideration.
• Reimbursement for mileage to and from medical
treatment may be requested if travel exceeds 15 miles.
If the authorized treating physician
restricts an injured employee’s ability to
work, such as limiting the number of
hours worked or the type of work
performed, it is very important that the
physician’s instructions and restrictions
are followed at all times. Failure to report
for light duty offered by your employer
may terminate your temporary disability
benefits.
Temporary Disability Benefits
Disability begins when the authorized treating physician
takes an employee off work. Temporary disability benefits
replace lost wages and are due beginning on the eighth
day of the disability. If the disability lasts fourteen (14)
days, benefits will be paid back to the first day of disability.
Temporary disability benefits are usually two-thirds (⅔) of
the injured worker’s average weekly wages earned during
the 52 weeks prior to the injury. If you are able to work,
but your average weekly earnings are reduced because of
work restrictions, you may be entitled to partial disability
benefits.
You should stay in contact with your
employer. Temporary disability benefits
are usually paid by the employer or its
insurance company. The Division of
Workers’ Compensation does not pay
these benefits.
Remember…
You can call the Ombudsman Program of the
Tennessee Division of Workers’ Compensation at 1800-332-2667. A Workers Compensation Specialist
will answer your questions or direct you to someone
that can.
FREQUENTLY ASKED QUESTIONS
Does an injured employee have to pay for medical
treatment for a compensable injury?
No. Injured employees are not responsible for the costs of
medical treatment provided by the authorized physician for a
compensable claim.
What options does an employee have if they disagree
with the authorized treating physician’s findings or
recommended medical treatment?
The employer or insurance company is usually not required
by law to offer a second opinion, but you can always ask for it
anyway. The employee may, however, obtain a second
opinion or additional medical treatment with any doctor at
his/her own expense.
What if I’m not receiving the benefits I deserve?
You can call the Workers’ Compensation Division at
1-800-332-2667. A Workers’ Compensation Ombudsman will
help you with your need for assistance.
Submitting a completed Petition for Benefit
Determination available at: process. will speed up the
Will an employee need to use his/her sick or vacation
time while off work due to a compensable injury?
It depends. An employee taken off work by the authorized
treating physician for less than 14 days is not entitled to
temporary disability benefits for the first seven (7) days of
work missed. Injured employees should review their
company’s policies about this unpaid time. If the authorized
treating physician requires the injured employee to miss more
than 14 days; however, benefits are due from the first day of
disability.
Is an injured employee paid for the time spent attending
doctor’s appointments during work hours?
Not unless you’re company has a policy to pay for this time.
Which employers must provide workers’ compensation
coverage for their employees?
All employers with five or more full- or part-time employees
must carry workers’ compensation insurance. In the
construction or mining industry however, employers must
provide coverage even if there is only one employee.
Construction employers may exempt themselves from the
workers’ compensation coverage requirements by applying
for an exemption; but, all employees in construction must be
covered.
Information about the Workers’ Compensation Exemption
Registry is available at:
http://tnbear.tn.gov/WC/Default.aspx or by calling the
Tennessee Secretary of State’s office at 615-741-2286.
Tennessee Division of Workers’ Compensation ♪ Suite 1-B ♪
220 French Landing Drive ♪ Nashville, TN 37243
TENNESSEE WORKERS’ COMPENSATION INSURANCE
Employers: The law requires this notice to be conspicuously posted at the employer’s place of business so all
employees have access to it.
WHO IS REQUIRED TO HAVE WORKERS’ COMPENSATION INSURANCE?
All employers with five (5) or more full or part-time employees.
All employers engaged in the mining and production of coal with one (1) or more employees.
All workers in the construction industry unless they are specifically exempted.
To confirm if an employer is subject to the workers’ compensation law and if so to obtain the name of the
workers’ compensation insurance company contact:
__________________________________________________________________________________
Name of employer representative authorized to provide information on workers’ compensation
__________________________________________________________________________________
Telephone number of employer representative to provide information on workers’ compensation
__________________________________________________________________________________
Address of employer representative to provide information on workers’ compensation
WHAT SHOULD AN EMPLOYEE DO IF INJURED AT WORK?
1. Report the injury to the employer immediately. Employer notification is required.
and 2. Select a treating physician from a panel provided by the employer.
To report an injury contact:
__________________________________________________________________________________
Name of employer representative to notify in event of a work related injury
__________________________________________________________________________________
Telephone number of employer representative to notify in event of a work related injury
__________________________________________________________________________________
Address of employer representative to notify in event of a work related injury
WHAT SHOULD AN EMPLOYER DO WHEN AN INJURY IS REPORTED?
1.
and 2.
Immediately complete a First Report of Work Injury form and send it to the workers’ compensation insurance
company or the third party administrator to be filed with the Tennessee Dept. of Labor and Workforce
Development, Workers’ Compensation Division.
Offer a panel of physicians.
The employer shall designate a group of three (3) or more physicians or surgeons not associated together in
practice from which the injured employee shall have the privilege of selecting the operating surgeon or the
attending physician. If the injury is a back injury, the panel shall be expanded to four (4), one of whom must
be a doctor of chiropractic. If a doctor of chiropractic is chosen, chiropractor visits may be authorized for up to
twelve (12) visits per back injury. More than twelve (12) visits to such doctor of chiropractic must be
specifically approved by the employer or insurance carrier. The provisions for chiropractic care shall not apply
to workers’ compensation self insurer pools established pursuant to Section 50-6-405(a)(1). If the injury
requires the treatment of physician or surgeon who practices orthopedic or neuroscience medicine then the
employer may appoint a panel of physicians or surgeons practicing orthopedic or neuroscience medicine
consisting of five (5) physicians, with no more than four (4) physicians affiliated in practice together. The
employee may select a treating physician or surgeon from the employer panel.
The Tennessee Department of Labor and Workforce Development, Division of Workers’ Compensation, has
staff available to help both employees and employers. For more information contact:
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
DIVISION OF WORKERS’ COMPENSATION
220 FRENCH LANDING DRIVE
NASHVILLE, TENNESSEE 37243-1002
615-532-4812 OR TOLL FREE 1-800-332-2667 OR 1-800-332-2257 (TDD)
www.tn.gov/labor-wfd/wcomp.html
LB-0922 (REV. 03/12)
RDA 10183
SEGURO DE ACCIDENTES DE TRABAJO DE TENNESSEE
Empleadores: La ley exige que se ponga este aviso en un lugar del negocio del empleador bien visible para que todos los
empleados tengan acceso al mismo.
¿QUIÉNES ESTÁN OBLIGADOS A TENER SEGURO DE ACCIDENTES DE TRABAJO?
Todo empleador que tenga cinco (5) o más de cinco empleados de horario completo o de medio horario.
Todo empleador que se dedique a la explotación de minas y la producción de carbón que tenga un (1) empleado o más de
un empleado.
Todos los trabajadores de la industria de la construcción a menos que específicamente están exentos.
Para comprobar si un empleador está sujeto a la ley de accidentes de trabajo y si ese fuera el caso, para obtener el nombre
de la compañía de seguro de accidentes de trabajo a contactar:
__________________________________________________________________________________
Nombre del representante del empleador
__________________________________________________________________________________
Número de teléfono del representante del empleador
__________________________________________________________________________________
Dirección del representante del empleador
(el nombre, la dirección y el número de teléfono del representante del empleador autorizado a dar información sobre indemnización por accidentes de
trabajo)
¿QUÉ DEBE HACER UN EMPLEADO SI SE LESIONA EN EL TRABAJO?
1.
y 2.
Notificar al empleador de la lesión inmediatamente. Es obligatorio notificar al empleador.
Escoger a un médico que le atienda de la lista que le dé el empleador.
Para notificar una lesión póngase en contacto con:
__________________________________________________________________________________
Nombre del representante del empleador
__________________________________________________________________________________
Número de teléfono del representante del empleador
__________________________________________________________________________________
Dirección del representante del empleador
(el nombre, la dirección y el número de teléfono del representante del empleador autorizado a dar información sobre indemnización por accidentes de
trabajo)
¿QUÉ DEBE HACER EL EMPLEADOR CUANDO SE LE NOTIFICA DE UNA LESIÓN?
1.
y 2.
Llenar inmediatamente el formulario Primera Notificación de Accidente de Trabajo y enviarlo a la compañía de
seguro de accidentes de trabajo o al administrador del seguro contra tercera persona para que lo registre en el
Departamento de Trabajo y Desarrollo Laboral de Tennessee, División de Accidentes de Trabajo.
Ofrecer una lista de médicos.
El empleador deberá nombrar un grupo de tres (3) médicos o cirujanos o más que no estén afiliados a la misma
oficina y de los cuales el empleado lesionado tendrá el privilegio de escoger ya sea el médico que le va a atender o
el cirujano que le va a operar. Si la lesión es una lesión de la espalda, la lista aumentará a cuatro (4), entre los
cuales habrá un médico quiropráctico. Si ud escoje un médico quiropráctico, las visitas pueden ser autorizadas
hasta doce (12) vezes por la lesión de espalda. Si ud require más de doce (12) visitas al mismo médico
quiropráctico tendra que tener autorización de su justador de seguransa or empleador. Las provisiones para el
cuidado del quiropráctico no se aplicarán grupos de autoasegurador establecidas conforme a la Sección 50-6-405
(a) (1). Si es una lesión que requiere que le atienda un médico o cirujano que ejerce la medicina ortopédica o de
neurociencias, entonces el empleador deberá nombrar un grupo de cinco (5) médicos o cirujanos que ejercen la
medicina ortopédica o de neurociencias de entre los cuales sólo cuatro (4) pueden estar afiliados a la misma
oficina. El empleado puede escoger un médico o cirujano de la lista del empleador para que le atienda.
El Departamento de Trabajo y Desarrollo Laboral de Tennessee, División de Accidentes de Trabajo tiene trabajadores
disponibles para ayudar tanto al empleado como al empleador. Si necesita más información, favor de ponerse en contacto
con:
DEPARTAMENTO DE TRABAJO Y DESARROLLO LABORAL DE TENNESSEE
DIVISIÓN DE ACCIDENTES DE TRABAJO
220 FRENCH LANDING DRIVE
NASHVILLE, TENNESSEE 37243-1002
615-532-4812 O LLAME GRATIS AL 1-800-332-2667 O AL 1-800-332-2257 (TDD)
www.tn.gov/labor-wfd/wcomp.html
LB-0922SP (REV. 03/12)
RDA 10183
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
EMPLOYER’S FIRST REPORT OF WORK INJURY OR ILLNESS
JURISDICTION CLAIM # (STATE FILE #)
CLAIM TYPE CODE
MED ONLY
INDEMNITY
BECAME LOST TIME
BECAME MED ONLY
NOTIFY ONLY
TRANSFER
THE USE OF THIS FORM IS REQUIRED UNDER THE PROVISIONS OF THE
NAME OF INSURANCE CARRIER
CARRIER FEIN
CLAIMS ADMIN FIRM NAME (IF DIFFERENT FROM
CARRIER)
FEIN OF CLMS ADM
COMPENSATION TRANSACTION FOR THE PURPOSE OF COMMITTING
FRAUD. PENALTIES INCLUDE IMPRISONMENT, FINES AND DENIAL OF
INSURANCE BENEFITS.
CLAIMS ADJUSTER NAME
CLMS ADJ PHONE #
CLAIMS ADM/CARRIER
CLAIMS ADM CLAIM # (INSURER CLAIM #)
OSHA LOG CASE #
TENNESSEE WORKERS'
COMPLETED
AND
E MPLOYER
POLICY
EMPLOYER FEIN
CITY
STATE
INSURED NAME (PARENT CO. IF DIFFERENT THAN
EMPLOYER)
EMPLOYEE
WAGE
ZIP
PHONE NUMBER
INSURED REPORT #
ZIP
POLICY NUMBER
EFF DATE
MI
GENDER
MALE
FEMALE
UNKNOWN
DEPARTMENT REGULARLY
WORKED
ADRRESS LINE 1 & 2
EMPLOYER LOCATION
EMPLOYMENT STATUS CODE
FULL TIME/REGULAR
PART TIME
PIECE WORKER
SEASONAL
VOLUNTEER
APPRENTICE FULL TIME
APPRENTICE PART TIME
EXP DATE
PHONE INCL AREA CODE
OCCUPATION DESCRIPTION
CITY
STATE
SSN
ACCIDENT/INJURY
STATE
SIC CODE
SELF INSURED?
YES
NO
FIRST
DATE OF BIRTH
PERIOD
HOURLY
DAILY
WEEKLY
BI-WEEKLY
MONTHLY
ZIP
MARITAL STATUS
UNMARRIED, SINGLE,
DIVORCED
DATE OF HIRE
MARRIED
SEPARATED
UNKNOWN
NCCI CLASS CODE
SALARY CONTINUED IN LIEU OF COMPENSATION
NUMBER OF DAYS WORKED PER
WEEK
FULL WAGES PAID FOR DATE OF INJURY
PM
YES
NO
NO
TIME OF INJURY
COULD NOT BE DETERMINED
DATE EMPLOYER NOTIFIED OF INJURY
BODY PART AFFECTED CODE
DATE CLAIM ADM NOTIFIED OF INJURY
HOW INJURY OR ILLNESS OCCURRED. DESCRIBE THE INCIDENT INCLUDING WHAT THE EMPLOYEE WAS DOING
JUST BEFORE, THE PART OF THE BODY AFFECTED AND HOW, AND OBJECT OR SUBSTANCE THAT DIRECTLY
HARMED THE EMPLOYEE.
DATE LAST DAY WORKED
AM
YES
DATE OF INJURY
TIME EMPLOYEE BEGAN WORK ON INJURY DATE
AM
PM
NATURE OF INJURY CODE
CAUSE OF INJURY CODE
DATE DISABILITY BEGAN
RETURN TO WORK DATE (IF APPLICABLE)
DATE OF DEATH (IF APPLICABLE)
IF DEATH CLAIM, GIVE # DEPENDENTS FOR EACH RELATIONSHIP
DID INJURY/ILLNESS OCCUR ON EMPLOYER’S
PREMISES?
YES
NO
WIDOW
WIDOWER
MOTHER
FATHER
____ DAUGHTER
____ SON
____ SISTER
____ BROTHER
____ HANDICAPPED CHILD
ADDRESS WHERE INJURY OCCURRED (IF OTHER THAN EMPLOYER’S PREMISES)
CITY
STATE
PHYSICIAN NAME
TREATMENT
BE
CARRIER
NATURE OF BUSINESS
EMPLOYEE LAST NAME
CITY
DATE PREPARED
LB-0021 (REV. 12/07)
TOTAL # DEPENDENTS
COUNTY OF INJURY
ZIP
HOSPITAL OR OFF SITE TREATMENT NAME
ADDRESS LINE 1 AND 2
INITIAL TREATMENT
NO MEDICAL TREATMENT
OTHER
MUST
INSURANCE
IF YOU HAVE QUESTIONS, THE STATE NOW HAS A BENEFIT REVIEW
SYSTEM WHERE A WORKERS' COMPENSATION SPECIALIST CAN
PROVIDE ASSISTANCE. CALL 1-800-332-2667 (TDD).
EMPLOYER ADDRESS LINE 1 AND LINE 2
WAGE
LAW AND
YOUR
IT IS A CRIME TO KNOWINGLY PROVIDE FALSE, INCOMPLETE OR
MISLEADING INFORMATION TO ANY PARTY TO A WORKERS'
CITY
EMPLOYER NAME
WITH
IMMEDIATELY AFTER NOTICE OF INJURY.
CLAIM HANDLING OFFICE ADDRESS LINE 1 AND LINE 2
$
COMPENSATION
FILED
ADDRESS LINE 1 AND 2
STATE
ZIP
MINOR BY EMPLOYER
MINOR BY CLINIC/HOSPITAL
PREPARER’S NAME & TITLE
CITY
HOSPITALIZED > 24 HRS
EMERGENCY CARE
PREPARER’S COMPANY NAME
STATE
ZIP
FUTURE MAJOR MEDICAL/LOST TIME
ANTICIPATED
PHONE NUMBER
RDA 10183
FORM C-42
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
220 French Landing Dr.
Nashville, Tennessee 37243-1002
Website: www.tn.gov/labor-wfd/wcomp.html
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN
In compliance with the Tennessee Workers' Compensation Law, T.C.A. Section 50-6-204
Upon the report of a workplace injury, an employer should provide the employee, in writing an Agreement Between
Employer/Employee Choice Of Physician Form C-42. The form must indicate the name of the physician chosen by
the injured employee, be signed by the employee with a copy given to the employee, and the original kept on file with
the employer. Employees traveling more than 15 miles one way to or from medical treatment may seek reimbursement
from the insurance carrier for their travel expense.
The injured employee must submit to examination by the employer's physician at all reasonable times if requested to
do so by the employer, but the employee shall have the right to have the employee's own physician present at such
examination, in which case the employee shall be liable to the employee’s physician for that physician's services. If
the injured employee refuses to comply with any reasonable request for examination or to accept the medical or
specialized medical services that the employer is required to furnish under this chapter, the injured employee's right to
compensation shall be suspended and no compensation shall be due and payable while the injured employee continues
to refuse.
For injuries prior to July 1, 2014, the injured employee shall accept the medical benefits afforded hereunder;
provided, the employer shall designate a group of three (3) or more reputable physicians or surgeons not associated
together in practice, if available in that community, from which the injured employee shall have the privilege of
selecting the operating surgeon or the attending physician. If the injury is a back injury, the statutory panel must be
expanded to 4, one of whom must be a chiropractor with treatment limited to 12 chiropractic visits. Further, if the
injury or illness requires the treatment of a physician or surgeon who practices orthopedic or neuroscience medicine,
the employer may appoint a panel practicing orthopedic or neuroscience medicine consisting of 5 physicians, with no
more than 4 physicians affiliated in practice. If there are not enough physicians available within the community of the
injured worker, names of physicians from outside the community should be added. If the employer provides this panel,
the injured employee shall be entitled to have a second opinion on the issue of surgery, impairment, and a diagnosis
from that same panel.
For injuries on or after July 1, 2014, the injured employee shall accept the medical benefits afforded under this
section; provided, that in any case when the employee has suffered an injury and expressed a need for medical care, the
employer shall designate a group of three (3) or more independent reputable physicians or surgeons, chiropractors or
specialty practice groups if available in the injured employee’s community, from which the injured employee shall
select one (1) to be the treating physician. If three (3) or more independent reputable physicians, surgeons,
chiropractors or specialty practice groups are not available in the employee's community, the employer shall provide a
list of three (3) independent reputable physicians, surgeons, chiropractors or specialty practice groups, within a one
hundred (100) mile radius of the employee's community. When necessary, the treating physician selected shall make
referrals to a specialist physician, surgeon, or chiropractor and immediately notify the employer. The employer shall be
deemed to have accepted the referral, unless the employer, within three (3) business days, provides the employee a
panel of three (3) or more independent reputable physicians, surgeons, chiropractors or specialty practice groups. In
this case, the employee may choose a specialist physician, surgeon, chiropractor or specialty practice group to provide
treatment only from the panel provided by the employer. When the treating physician or chiropractor refers the
injured employee, the employee shall be entitled to have a second opinion on the issue of surgery and diagnosis from a
physician or chiropractor specified in the initial panel of physicians provided by the employer. The employee's
decision to obtain a second opinion shall not alter the previous selection of the treating physician or chiropractor.
If you have any questions or need assistance in completing this form, call 1-800-332-2667.
FORM C-42
DIVISION OF WORKERS' COMPENSATION
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPME NT
220 French Landing Dr.
Nashville, Tennessee 37243-1002
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN
It is a crime to knowingly provide false, incomplete or misleading information to any party to a workers' compensation
transaction for the purpose of committing fraud. Penalties include imprisonment, fines and denial of insurance benefits.
In compliance with the Tennessee Workers' Compensation Law, T.C.A. Section 50-6-204
1.
Physician’s Name
Telephone
Office Address
City
State
Zip
2.
Physician’s Name
Telephone
Office Address
City
Zip
State
3.
Physician’s Name
Telephone
Office Address
City
State
Zip
4.
Physician’s Or Chiropractor’s Name
Telephone
Office Address
City
State
Zip
5.
Physician’s Name
Telephone
Office Address
City
State
Zip
According to the provisions of this agreement, I hereby have selected the following physician from the list
provided to me by my employer.
Physician chosen:
Date of selection:
Date of injury:
Date of appointment:
Employer’s Name
Employee’s Name
Street Address
Street Address
City
Telephone
Employer’s Signature
State
Email
Zip
City
Telephone
State
Zip
Email
Employee’s Signature
Employee’s Social Security Number
State File Number
LB-0382 (REV. 07/14)
RDA 10183
FORMULARIO C-42
DEPARTAMENTO DE TRABAJO Y DESARROLLO DE LA FUERZA LABORAL DE TENNESSEE
TENNESSEE DEPARTMENT OF LABOR & WORKFORCE DEVELOPMENT
División de Compensación de Trabajadores / Division of Workers’ Compensation
220 French Landing Dr., Nashville, Tennessee 37243-1002
ACUERDO DE SELECCIÓN DE MÉDICOS ENTRE EL EMPLEADOR Y EL EMPLEADO
AGREEMENT BETWEEN EMPLOYER/EMPLOYEE CHOICE OF PHYSICIAN
Es un delito proveer intencionalmente información falsa, incompleta o engañosa a cualquiera de las partes de una transacción relacionada
con el seguro de compensación de trabajadores con la intención de cometer un fraude. Las sanciones incluyen cárcel, multas y denegación de
beneficios de seguros.
De conformidad con la Ley de Compensación de Trabajadores de Tennessee, T.C.A. Sección 50-6-204
El empleado lesionado aceptará los beneficios médicos concedidos por la presente y se estipula que el empleador designará a un grupo
de tres (3) o más médicos o cirujanos de buena reputación cuyos consultorios no estarán asociados entre sí, cuando sea posible en esa comunidad,
entre los cuales el empleado lesionado tendrá el privilegio de seleccionar un cirujano y un médico de cabecera. Si ocurre una lesión en la espalda,
el panel exigido por ley se ampliará a 4, uno de los cuales deberá ser un quiropráctico cuyo tratamiento se limitará a 12 consultas quiroprácticas.
Adicionalmente, si la lesión o enfermedad requiere tratamiento de un médico o cirujano que ejerza medicina ortopédica o neurociencia, el
empleador podrá asignar un panel de medicina ortopédica o neurociencia que conste de 5 médicos, con no más de 4 médicos afiliados entre sí. Si
el empleador provee este panel, el empleado lesionado tendrá derecho a solicitar una segunda opinión sobre el tema de cirugía, discapacidad y un
diagnóstico de dicho panel.
1.
2.
3.
4.
5.
NOMBRE del MÉDICO / PHYSICIAN NAME
TELÉFONO / TELEPHONE
DIRECCIÓN del CONSULTORIO / OFFICE ADDRESS , CIUDAD / CITY
ESTADO / STATE
NOMBRE del MÉDICO / PHYSICIAN NAME
TELÉFONO / TELEPHONE
DIRECCIÓN del CONSULTORIO / OFFICE ADDRESS, CIUDAD / CITY
ESTADO / STATE
NOMBRE del MÉDICO / PHYSICIAN NAME
TELÉFONO / TELEPHONE
DIRECCIÓN del CONSULTORIO/ OFFICE ADDRESS , CIUDAD / CITY
ESTADO / STATE
NOMBRE del MÉDICO o QUIROPRÁCTICO / CHIROPRACTOR NAME
TELÉFONO / TELEPHONE
DIRECCIÓN del CONSULTORIO/ OFFICE ADDRESS , CIUDAD / CITY
ESTADO / STATE
NOMBRE del MÉDICO / PHYSICIAN NAME
TELÉFONO / TELEPHONE
DIRECCIÓN del CONSULTORIO/ OFFICE ADDRESS , CIUDAD / CITY
ESTADO / STATE
CÓDIGO POSTAL / ZIP CODE
CÓDIGO POSTAL / ZIP CODE
CÓDIGO POSTAL / ZIP CODE
CÓDIGO POSTAL / ZIP CODE
CÓDIGO POSTAL / ZIP CODE
(d)(1) "El empleado lesionado deberá someterse a un examen por parte del médico del empleador cada vez que lo solicite razonablemente el
empleador, pero el empleado tendrá derecho a que el médico particular del empleado esté presente en dicho examen, en cuyo caso el
empleador será responsable ante dicho médico por sus servicios profesionales.”
(7) "Si el empleado lesionado rehúsa acatar cualquier solicitud de examen médico razonable o aceptar los servicios médicos o especializados que el
empleador debe proporcionar de conformidad con las disposiciones de la presente ley, se suspenderá el derecho que tiene dicho empleado
lesionado a recibir compensación y no se le adeudará ni pagará ninguna compensación si el empleado lesionado mantiene dicha negativa".
De conformidad con las disposiciones del presente acuerdo, he seleccionado los siguientes médicos de la lista que me ha proporcionado
mi empleador.
Médico seleccionado:
(Physician Chosen)
Fecha de la lesión:
(Date of Injury)
Fecha de la selección:
(Date of Selection)
Fecha de la cita:
(Date of Appointment)
Nombre del empleador / Employer’s Name
Nombre del empleado / Employee’s Name
Dirección / Street Address
Dirección / Street Address
Ciudad / City
Estado / State
Cód Postal / Zip
Ciudad / City
Teléfono / Telephone
Teléfono / Telephone
Employer’s Signature
Employee’s Signature
Estado / State
Cód Postal / Zip
Número de seguro social del empleado / Employee;s SSN
LB-0382 (REV. 01/14)
Número de expediente estatal / State File Number
RDA 10183
FORM C-31
TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT
Division of Workers' Compensation
MEDICAL WAIVER AND CONSENT
FOR INJURIES ON OR AFTER JULY 1, 2014, THIS FORM IS NOT REQUIRED.
It is a crime to knowingly provide false, incomplete or misleading information to any party
to a workers' compensation transaction for the purpose of committing fraud. Penalties
include imprisonment, fines and denial of insurance benefits.
THIS MEDICAL AUTHORIZATION FORM ONLY PERMITS THE EMPLOYER OR THE
DIVISION OF WORKERS' COMPENSATION TO OBTAIN MEDICAL INFORMATION
THROUGH ORAL OR WRITTEN COMMUNICATION, INCLUDING, BUT NOT LIMITED
TO, CHARTS, FILES, RECORDS, AND REPORTS IN THE POSSESSION OF A MEDICAL
PROVIDER AUTHORIZED BY THE EMPLOYER PURSUANT TO T.C.A. § 50-6-204 AND
A MEDICAL PROVIDER THAT IS REIMBURSED BY THE EMPLOYER FOR THE
EMPLOYEE'S TREATMENT.
I, __________________________________, having filed a claim for workers' compensation
benefits, do hereby authorize
______________________________________________________________________________
(Name of Medical Provider)
to furnish to my employer or my employer’s representative, and/or the Division of Workers'
Compensation any information or written material reasonably related to my work-related injury
for which I am claiming compensation.
I further authorize the release of the same information to me or my attorney.
The authorization includes, but is not restricted to, a right to review and obtain copies of all
records, x-rays, x-ray reports, medical charts, prescriptions, diagnoses, opinions and courses of
treatment.
A photocopy of the authorization may be accepted in lieu of the original.
Dated: _________________________, 20____.
____________________________________
Patient
__________________________
Social Security last four numbers
___________________________________
Witness
LB-0379 (REV. 07/14)
RDA 10183
FORM C-31 (DOCUMENTO C-31)
DEPARTAMENTO DE TRABAJO Y DESARROLLO LABORAL
DE TENNESSEE
División de Indemnización de los Trabajadores
EXONERACIÓN Y CONSENTIMIENTO MÉDICO
Es un crimen proveer información falsa deliberadamente, incompleta o errónea a cualquiera de las
partes para una transacción de indemnización de trabajadores con el propósito de cometer fraude.
Las penas legales incluyen encarcelamiento, multas y denegación de los beneficios del seguro.
ESTE FORMATO DE AUTORIZACIÓN MÉDICA SOLAMENTE PERMITE AL EMPLEADOR O
A LA DIVISIÓN DE INDEMNIZACIÓN DE LOS TRABAJADORES OBTENER INFORMACIÓN
MÉDICA A TRAVÉS DE COMUNICACIÓN ORAL O ESCRITA, INCLUYENDO, PERO NO
LIMITÁNDOSE A, DIAGRAMAS, EXPEDIENTES, REGISTROS E INFORMES EN POSESIÓN
DE UN PROFESIONAL MÉDICO AUTORIZADO POR EL EMPLEADOR, DE ACUERDO CON
T.C.A. § 50-6-204, Y UN PROFESIONAL MÉDICO A QUIEN EL EMPLEADOR LE
REEMBOLSE POR EL TRATAMIENTO DEL EMPLEADO.
Yo, __________________________________, habiendo presentado una demanda para beneficios de
indemnización de trabajadores, por medio de la presente autorizo al doctor
______________________________________________________________________________
(Nombre del profesional médico)
a facilitarle a mi empleador (o al representante de mi empleador) y/o a la División de Indemnización
de los Trabajadores cualquier información razonablemente relacionada, o documentos escritos
razonablemente relacionada con mi herida derivada de un accidente laboral. Tambien autorizo la
distribución de la misma información a mi abogado. La autorización incluye, pero no se restringe a, el
derecho a revisar y obtener copias de todos los registros en el historial médico, rayos x, informes de
rayos x, diagramas médicos, prescripciones, diagnósticos, opiniones y ciclos de tratamiento.
Se puede aceptar una fotocopia de la autorización en vez de la original.
Fechado:
_________________________, 20____.
____________________________________
Paciente
__________________________
Últimas cuatro cifras del número
de Seguro Social
___________________________________
Testigo
The Division certifies that this Spanish Medical Waiver and Consent (Form C-31) is
an exact translation of the English Form C-31.
LB-0379 (REV. 08/09)
RDA 10183
First Fill
Temporary Pharmacy Card
Making it easy to get your workers’ compensation prescriptions filled.
Employer:
Print this page immediately upon receiving notice of injury, fill in the
information below and give it to your employee.
Injured Employee:
1. If you need a prescription filled for a work-related injury or illness, go to a Tmesys
network pharmacy.
2. Give this page to the pharmacist.
3. The pharmacist will fill your prescription at no cost.
Attention Pharmacists: Call 800.964.2531 to establish First
Fill benefit eligibility and obtain the ID# for online adjudication
of approved benefits for the injured worker.
Prescription Card
CARRIER/TPA
Sedgwick
EMPLOYER/OTHER ENTITY
Atlas General Insurance
Tmesys is the designated PBM for this patient.
INJURED WORKER NAME
Tmesys Pharmacy
Help Desk 800.964.2531
DATE OF INJURY
SOCIAL SECURITY NUMBER
Please provide directly to Pharmacist
Notice to Cardholder: This card should be presented to your pharmacy to receive
medication for your work-related injury. It is only valid within 30 days of your date of injury.
For information regarding the program or to find nearby pharmacies call 866.599.5426.
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(To create a card for your wallet, cut along outer line and fold in half.)
Pharmacist:
1. Call the Tmesys Pharmacy Help Desk at 800.964.2531.
2. Provide the information listed above.
3. The Help Desk will provide an ID number for adjudication.
Finding a Network Pharmacy
Use one of these easy methods to find a network pharmacy:
■ Visit one of the following pharmacy chains:
Duane Reade
Walmart
Walgreens
Kroger
CVS
Rite Aid
■
■
Publix
Safeway
Use our pharmacy locator online: www.pmsionline.com/pharmacy-center.
Call us: 866.599.5426
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
.
Tmesys Retail Pharmacy Network*
More than 60,000 pharmacies, including large chains and many neighborhood
independent pharmacies, meaning that your prescription can be filled at most
pharmacies nationwide.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription
Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket
Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe
Pharmacy (various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount
Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets
Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy &
Discount
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart
Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*List subject to change. This is a partial listing only.
© 2010 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Tarjeta temporal
para surtir por primera vez sus recetas en farmacias
Facilita la tarea de surtir las recetas correspondientes a la compensación por accidentes o
enfermedades laborales.
Empleador:
Imprima esta página inmediatamente después de recibir un aviso de lesión, complete
la información que se encuentra a continuación y entréguesela a su empleado.
Empleado lesionado:
1. Si necesita que se le surta una receta por una lesión o enfermedad relacionada con
el trabajo, diríjase a una farmacia de la red Tmesys.
2. Entréguele esta página al farmacéutico.
3. El farmacéutico le surtirá la receta sin costo alguno.
At. farmacéuticos: Llamen al 800.964.2531 a fin de establecer la elegibilidad para el beneficio de surtir por primera vez su receta y obtener el
número de ID para la adjudicación en línea de los beneficios aprobados
para el trabajador lesionado.
Prescription Card
COMPAÑÑÍA DE SEGUROS/ADMINISTRADOR EXTERNO (TPA)
EMPLEADOR/OTRA ENTIDAD
Sedgwick
Atlas General Insurance
Tmesys es la administradora de beneficios de farmacia (PBM) asignada a
este paciente.
NOMBRE DEL EMPLEADO LESIONADO
NÚMERO DE SEGURO SOCIAL
FECHA EN QUE OCURRIÓ LA LESIÓN
Entregar directamente al farmacéutico
Aviso al titular de la tarjeta: Para recibir los medicamentos correspondiente a la
lesión laboral sufrida, debe presentarle esta tarjeta al farmacéutico. Solo es válida durante
30 días a partir de la fecha de la lesión. Para obtener información sobre el programa o para
encontrar farmacias cercanas a usted, llame al 866.599.5426
RxBin
RxPCN
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct. #
(Si desea llevar la tarjeta en la billetera, corte a lo largo de la línea exterior y dóblela por la mitad)
Farmacéutico:
1. Llame al servicio de asistencia de farmacias de Tmesys al 800.964.2531.
2. Suministre la información que figura arriba.
3. El servicio de asistencia le dará un número de ID correspondiente a la adjudicación.
Cómo encontrar una farmacia de la red
Para encontrar una farmacia de la red, use uno de estos sencillos métodos:
■
Visite alguna de las siguientes cadenas de farmacias:
Walgreens
Rite Aid
Walmart
CVS
Duane Reade
Kroger
Publix
Safeway
■
Use nuestro localizador de farmacias en línea: www.pmsionline.com/pharmacy-center.
■
Llámenos: 866.599.5426
© 2013 PMSI, Inc. All rights reserved. C1257B-1010-01-SCMS
Red de farmacias minoristas de Tmesys* Más de 65,000 farmacias, entre ellas grandes
cadenas, así como farmacias independientes, lo cual permite que le puedan surtir sus recetas en la mayoría de farmacias del país.
Accredo Health Group
Anchor Pharmacy
Arrow Prescription Center
Aurora Pharmacy
Baker’s Pharmacy
Bartell Drugs
Bashas’ United Drug
Bel Air Pharmacy
Big Y Pharmacy
Biggs Pharmacy
Bi-Lo
Bi-Mart
Bioscrip Pharmacy
BJ’s Pharmacy
Brookshire’s Pharmacy
Bruno’s Pharmacy
Buehler’s Pharmacy
Caremark Pharmacy
Carle Rx Express
Carrs Quality Center
City Market Pharmacy
Clinic Pharmacy
Coborn’s/Cash Wise
Concord Drugs
Costco Pharmacy
Cub Pharmacy
CVS Pharmacy
D&W Pharmacy
Dahl’s Pharmacy
Dierbergs
Dillon Pharmacy
Discount Drug Mart
Doc’s Drug
Dominick’s Finer Foods
Drug Emporium
Drug Mart
Drug Town
Drug Warehouse
Drugs For Less
E. W. James Pharmacy
Eagle Pharmacy
Eaton Apothecary
Econofoods Pharmacy
Edwards Pharmacy
Fagen Pharmacy
Family Drug Store
Family Fare Pharmacy
Family Pharmacy
Familymeds Pharmacy
Farm Fresh Pharmacy
Farmer Jack Pharmacy
Food 4 Less Pharmacy
Food City Pharmacy
Food Lion Pharmacy
Food Town Pharmacy
Food World Pharmacy
Fred Meyer Pharmacy
Fred’s Pharmacy
Fruth Pharmacy
Fry’s Pharmacy
Gemmel Pharmacy
Gentiva Health Services
Genuardi’s Pharmacy
Gerbes Pharmacy
Giant Eagle Pharmacy
Giant Pharmacy
Glen’s Pharmacy
Good Day Pharmacy
Grand Union Pharmacy
Gristedes Pharmacy
H-E-B Pharmacy
Haggen Foods
Hannaford
Happy Harry’s
Harmons Pharmacy
Harps Pharmacy
Harris Teeter
Hartig Drug
Harvest Foods Pharmacy
Harveys Supermarket Pharmacy
Hen House Pharmacy
Hi-School Pharmacy
Homeland Pharmacy
Hometown Pharmacy
Hy-Vee Pharmacy
Ingles Pharmacy
Kmart Pharmacy
Kerr Drug
King Kullen Pharmacy
King Soopers Pharmacy
Kings Pharmacy
Kinney Drugs
Klingensmith’s
Knight Drugs
Kohl’s Pharmacy
Kohll’s Pharmacy
Kopp Drug
Kroger Pharmacy
Lewis Pharmacy
Lifechek Drug
Longs Drug
Louis and Clark
Lowes Marketplace
Marc’s Pharmacy
Marsh Drugs
Martin’s Pharmacy
May’s Drug Store
Med-Fast Pharmacy
Medical Arts Pharmacy
Medicap Pharmacy
Medicine Shoppe Pharmacy
(various)
Med-X Drug
Meijer Pharmacy
Minyard Pharmacy
Morton Pharmacy
Mr. Discount Drugs
Navarro Discount Pharmacies
NeighborCare Pharmacy
No Frills Pharmacy
Network Pharmacy
Owens Pharmacy
P&C Food & Pharmacy
Pamida Pharmacy
Park Nicollet Pharmacy
Pathmark Pharmacy
Pavilions Pharmacy
PharmaCare Pharmacy
Pharmacy Express
Pharmacy Plus
Pick ’N Save Pharmacy
Piggly Wiggly
PrairieStone Pharmacy
Price Chopper Pharmacy
Price Cutter Pharmacy
Publix Pharmacy
Q Pharmacy
QFC Pharmacy
Quality Markets Pharmacy
QuickChek Pharmacy
QVL Pharmacy
Rainbow Pharmacy
Raley’s Drug Center
Ralphs Pharmacy
Randalls Pharmacy
Reasors Pharmacy
Rite Aid Pharmacy
Ritzman Natural Health
Rosauers Pharmacy
RXD Pharmacy
Sack ’n Save Pharmacy
Safeway Pharmacy
Sam’s Pharmacy
Save Mart Pharmacy
Save-Rite Pharmacy
Schnucks Pharmacy
Scolaris Pharmacy
Sedanos Pharmacy
Shaw’s Pharmacy
Shaws/Osco Pharmacy
Shop ’n Save Pharmacy
Shopko Pharmacy
Shoppers Pharmacy
ShopRite Pharmacy
Snyder Drug Emporium
Southern Family Market
Star Pharmacy
Stop & Shop Pharmacy
Sunscript Pharmacy
Super 1 Pharmacy
Super D
Super G
Super Foodmart Pharmacy
Super Fresh Pharmacy
Super Rx Pharmacy
Sweetbay
The Pharm
Thriftway Drugs
Thrifty White Drug
Times Pharmacy
Tom Thumb Pharmacy
Tops Pharmacy
U-Save Pharmacy
Ukrops Pharmacy
United Pharmacy
USA Drug
Vix Pharmacy
Vons Pharmacy
VG’s Pharmacy
Waldbaum’s Pharmacy
Walgreens
Wal-Mart Pharmacy
Wegman Pharmacy
Weis Pharmacy
White Drug
Winn-Dixie
Yokes Pharmacy
*Lista sujeta a cambios. Ésta es sólo una lista
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
P.O. Box 152539
Tampa, FL 33684-2539
Prescription Card
«DOI»
DOI
«subID»
ID#
Name «Patientname»
Carrier «Carrier»
PERSONAL & CONFIDENTIAL
Important Insurance Claim Document Enclosed
Questions?
Prescription Delivery By Mail
In addition to providing access to your medications at a local pharmacy, Tmesys
can also deliver your medications to your home through our PMSI Mail Order
program at no cost. Using this convenient program means you will not have to
drop off or pick up your prescription or wait in line while it is being ¿lled.
For more information or to sign up, call 1.800.304.1764 or go to
www.pmsionline.com/pharmacy-center, click on Mail Order Overview.
Prescription Card
¿Necesitas ayuda en español?
Llame al 1.866.599.5426
NDC
RxBin
004261
or
CAL
or
RxPCN
Issuer (80840) 9151014609
Injury Date «DOI»
«subID»
ID#
«Patientname»
Name
Carrier/TPA «Carrier»
Envoy
002538
Envoy Acct.#
1.866.599.5426
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
RxBin
RxPCN
Issuer (80840)
NDC
Envoy
004261 or 002538
CAL
or Envoy Acct.#
9151014609
Note: Your use of this card is limited to those prescriptions
medically related to an injury that is considered to be covered
under the applicable state workers’ compensation law.
Attention Pharmacist: Tmesys is the designated
workers’ compensation PBM for this patient. Call Tmesys
with questions regarding transmission or rejection at:
1.800.964.2531.
Attention Cardholder: For questions regarding coverage
or to ¿nd a pharmacy call Tmesys at: 1.866.599.5426
or visit www.tmesys.com.
IMPORTANT: ONCE CARDS HAVE BEEN REMOVED PLEASE RETAIN THIS PORTION FOR YOUR RECORDS
Attention Pharmacist: Tmesys is the workers’
compensation PBM for this patient. For questions
regarding transmission, call 1.800.964.2531.
Taking Care of
<<PATIENTNAME>>
Using the Pharmacy Card
We want to make it easy for you to obtain the medication you need to recover from your
work-related injury. Just follow these steps:
1. Activate the card by calling the toll-free number.
2. Separate the attached cards and place one in your wallet and one on your key ring.
3. Give a card to the pharmacist next time you have a new prescription or refill.
4. Your prescription will be filled at no cost.
Finding a Pharmacy
You can use any pharmacy that is part of the Tmesys network to ¿ll your prescription—and
with over 60,000 locations, the card is accepted at most pharmacies nationwide. Finding
a network pharmacy is simple! Use one of the options below:
Ŷ Visit one of the following pharmacy chains:
Walgreens
Rite Aid
Walmart
Target
Duane Reade
Kroger
Publix
Safeway
Ŷ Go to one of these nearby pharmacies:
«Pharmacy1»
«Pharmacy2»
«Pharmacy3»
Ŷ Look up a pharmacy on the website: www.tmesys.com, click on Pharmacy Locator
and choose a search option.
Ŷ Call us toll free at 1.866.599.5426.
© 2011 PMSI, Inc. All Rights Reserved. SCMSMOD