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Workers Compensation

By John Brooks,2014-05-05 16:47
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Workers Compensation

    IATSE Local 115

    Workers’ Compensation

    Employee Information

    Revised 8/26/05

    Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 1 of 8

    Revised 7/10/05

In Case of Injury

If you have an emergency, please:

    ? Tell your steward

    ? Determine the situation and location

    ? Call 9-1-1 if an injury is life threatening

    ? Contact the Security Office at the venue (if applicable)

If you need urgent care, please:

    ? Tell your steward

    ? Steward gathers information about the accident

    ? Steward completes the paperwork required by employer (see employer/venue information).

Get as much information as possible including location, witnesses, type of injury and contributing factors.

Within 24 hours, the injured employee or the job steward should contact and forward required paperwork

    to office/person designated on employer/venue information.

Address to mail DWC-1 Form (to be completed for every injury):

    Division of Workers’ Compensation

    Office of Data Quality and Collection, Records Section

    200 East Gaines Street

    Tallahassee, FL 32399-4226

FCCJ-Wilson Center (Allegis Group - Aerotek)

    FCCJ-South Campus First Aid Kit location: Stage Mgr console and 11901 Beach Boulevard lighting booth Jacksonville, FL 32246 Security Office phone: (904) 646-2368 (904) 646-2222 Security Office location: Satellite office at

     loading dock. Main office (center of campus)

    campus commons.

Injury Reporting Procedure for Aerotek Employees:

Step 1: Injury Occurs

    Step 2: Immediately call Amanda Tyson or Angela Clyne @904-858-4200. If after hours leave a message

    on the Voice Mail.

    Step 3: Send the employee to one of the approved clinics.

    Step 4: Complete and fax the following forms to 904-858-4201/4202:

     **We must have these forms to process the Claim**

    1) Employee Incident Report

    2) Supervisor’s Notice of Injury

    Step 5: Take the following forms to the clinic with you:

    1) Protocol for the Treatment of Injured Employees

    2) Authorization for Medical Information

    3) Employee Medical Release Form

    Step 6: Fax the Employee Medical Release Form, and any other forms that you receive from the Clinic, to

    904-858-4201/4202.

    Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 2 of 8

    Revised 7/10/05

Provider: The Hartford

    The Medical Management Center, P.O. Box 7948, Wheaton, IL 60189

    (800) 762-0666

    Online Provider Search for Allegis/Aerotek (FCCJ)

    Solantic Walk In 410 Atlantic Blvd Urgent 2.67 904-241-0117 Urgent Care Jacksonville, FL 32266 Care Center

    Solantic Walk In 2401 Monument Rd Urgent 4.61 904-642-0337 Urgent Care Jacksonville, FL 32225 Care Center

    Solantic Walk In 12303 San Jose Blvd Urgent 12.62 904-288-0277 Urgent Care Jacksonville, FL 32223 Care Center

    Baptist Medical Center 1350 13th Ave S 6.54 904-247-2900 Hospital Beaches Jacksonville Beach, FL 32250

    Northeast Florida 4555 Emerson St Ste 115 Urgent Care Occupational Health 6.58 904-399-5959 Jacksonville, FL 32207 Center and Wellness

    Memorial Hospital 3625 University Blvd S 7.16 904-399-6111 Hospital Jacksonville Jacksonville, FL 32216

    Baptist Medical Center 14550 Saint Augustine Rd 7.66 904-393-2000 Hospital South Jacksonville, FL 32258

    800 Prudential Dr Baptist Medical Center 9.46 904-202-2000 Hospital Jacksonville, FL 32207

    St Vincents Medical 1800 Barrs St 10.96 904-308-7300 Hospital Center Jacksonville, FL 32204 Florida Theatre Performing Arts Center, Inc.

    128 East Forsyth Street, Suite 300 Provider: FHM (Florida Hospitality Mutual Jacksonville, FL 32202 Insurance Co.) (904) 355-5661 Policy Number: 30605778

     Effective Date: 10/01/04 Contact: Jackie Williams Expiration Date: 10/01/05 Phone: 904-355-5661 x237 Phone: (888) 346-3461

    Provider Website: www.fhmic.com

First Aid Kit location: DSR, Wardrobe Room, House Mgr. Office

Tell the Emergency Department employees that you are a member of a MCA (Managed Care

    Arrangement) and they must call the Notice of Injury (NOI) Center at (888) 346-3461 x353 within 24 hours

    for approval.

    The NOI Center will complete The First Report of Injury [LES Form DWC-1 (11/94)] with the steward or injured employee via telephone. Have the following information ready:

    ? Full name, address, telephone number of injured employee

    ? Occupation, date of birth, sex of injured employee

    ? The injured employee’s Social Security number

    Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 3 of 8

    Revised 7/10/05

    ? Date and Time of Accident

    ? Injury/Illness that occurred, part of body injured

    ? Company name, phone, address

    ? Place/address accident occurred

    ? Federal Employer ID# and FHM Policy Number

    ? Employee date of hire

    ? Did the employee return to work?

    ? Do you (the steward) agree with the accident?

    ? Name of physician or hospital where employee was sent for treatment

    Designated Medical Providers Link to spreadsheet when online

    Shands Jacksonville Medical Center-Clinical 24 Duval Hospital Center 655 W. 8th Street 32209 904-244-0411 904-549-3473 Hours

    Urgent Lakewood Care Kiely, Acute Care M-F 7-Duval Center Robert, M.D. Center 5987 Powers Avenue 32217 904-737-8686 904-448-5414 9 Atlantic M-F 8-Family 8 Sat Urgent Schwartz, Medical 9-6 Care William I., Center of Sun 9-Duval Center D.O. Jacksonville 13155 Atlantic Blvd. 32225 904-221-2222 904-221-2024 4

    Jacksonville Metropolitan Park (usually North Florida Payroll) 1410 Gator Bowl Blvd.

    Jacksonville, Fl. 32202

    Backstage Phone (904) 630-0263

First Aid Kit location: _____________

    Security Office phone: (904) 630-0837

    Security Office location: _____________

    Notify Security and Manager-On-Duty as soon as possible

    Jacksonville Symphony Association

    300 West Water Street, Suite 200 Provider: Bridgefield Employers Insurance Jacksonville, FL 32202 Company (904) 354-5479 Policy Number: BEIC 830-34709

     Effective Date: 7/1/05 Security Office phone: 633-6112 Expiration Date: N/A. Renewed yearly. Security Office location: Lobby Phone: ______________

     Provider Website: Contact: Sally Pettegrew (within 24 hours) http://www.summitholdings.com/bridgefield_empPhone: (904) 354-5479 loyers_insurance_company_florida_landing.html

First Aid Kit location: Large red case is located Stage Left in Jacoby at Stage Manager's Desk along with

    phone

    Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 4 of 8

    Revised 7/10/05

The crew has been given the # to call to report an injury during non-business hours, as well as what

    information they need to provide. In all cases, the information that will need to be provided to the

    workers’ compensation carrier include the employee’s date of birth, social security number, home address

    and home telephone number.

Designated Medical Providers include the following: Injuries can be treated at Southern Baptist Hospital

    of Florida, Inc., 14550 St. Augustine Rd., Jacksonville, St. Vincent's Medical Center, 1800 Barrs St.,

    Jacksonville, Baptist Medical Center Jacksonville, 800 Prudential Dr., Jacksonville, Baptist Medical

    Center of the Beaches, 1350 13th Ave. S., Jacksonville Beach and Arlington Acute Care, 1021 Cesery

    Blvd, and 5987 Powers Avenue, Jacksonville

    North Florida Payroll Services, Inc.

    P.O. Box 8005 Provider: FHM (Florida Hospitality Mutual Jacksonville, FL 32239 Insurance Co.) (904) 737-7909 Policy Number: 30610020

     Effective Date: 1/15/05 Contact: Rosemary Klemmt (within 24 hours) Phone: (888) 346-3461 Phone: (904) 737-7909 Provider Website: www.fhmic.com

Tell the Emergency Department employees that you are a member of a MCA (Managed Care

    Arrangement) and they must call the Notice of Injury (NOI) Center at (888) 346-3461 x353 within 24 hours

    for approval.

    The NOI Center will complete The First Report of Injury [LES Form DWC-1 (11/94)] with the steward or injured employee via telephone. Have the following information ready:

    ? Full name, address, telephone number of injured employee

    ? Occupation, date of birth, sex of injured employee

    ? The injured employee’s Social Security number

    ? Date and Time of Accident

    ? Injury/Illness that occurred, part of body injured

    ? Company name, phone, address

    ? Place/address accident occurred

    ? Federal Employer ID# and FHM Policy Number

    ? Employee date of hire

    ? Did the employee return to work?

    ? Do you (the steward) agree with the accident?

    ? Name of physician or hospital where employee was sent for treatment

    Designated Medical Providers Link to spreadsheet when online

County City Specialty Provider Office Name Address1 Zip Phone Hours North Florida Regional 6500 Medical Newberry 24 Alachua Gainesville Hospital Center Road 32605 352-333-4000 Hours Shands at Alachua General 801 S.W. 2nd Alachua Gainesville Hospital Hospital Avenue 32601 352-372-4321 M-F 8-6 Urgent Walk In Care Newcomer, First Care of 4881 N.W. 8th AccepteAlachua Gainesville Center Gary, M.D. Gainesville Avenue 32605 352-373-2340 d

    Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 5 of 8

    Revised 7/10/05

    M-F 8-6 Urgent Walk In Care Wilson, Scott First Care of 4881 N.W. 8th AccepteAlachua Gainesville Center A., M.D. Gainesville Avenue 32605 352-373-2340 d Lake City 340 N. Medical Commerce 24 Columbia Lake City Hospital Center Blvd. 32055 386-719-9000 Hours Shands Jacksonville Medical Center-655 W. 8th 24 Duval Jacksonville Hospital Clinical Center Street 32209 904-244-0411 Hours

    Urgent Lakewood Care Kiely, Robert, Acute Care 5987 Powers Duval Jacksonville Center M.D. Center Avenue 32217 904-737-8686 M-F 7-9 Atlantic Family Urgent Schwartz, Medical M-F 8-8 Care William I., Center of 13155 Atlantic Sat 9-6 Duval Jacksonville Center D.O. Jacksonville Blvd. 32225 904-221-2222 Sun 9-4 Florida 60 Memorial Hospital- Medical Flagler Palm Coast Hospital Flagler Parkway 32164 386-586-2000

    St. Flagler 400 Health St. Johns Augustine Hospital Hospital, Inc. Park Blvd. 32086 904-819-5155 24/7 Halifax Daytona Medical 303 N.Clyde 24 Volusia Beach Hospital Center Morris Blvd. 32114 386-254-4000 Hours Halifax Medical Urgent Center Daytona Care Atlantic 400 N.Clyde 24 Volusia Beach Center Campus Morris Blvd. 32114 386-239-5000 hours Florida 701 W. Hospital-Plymouth Volusia Deland Hospital Deland Avenue 32720 386-734-3320 M-F 8-5 Quick Care Sat. 8-2 Urgent Medical 650 W Walk In Care Treatment Plymouth AccepteVolusia Deland Center Centers, Inc. Avenue 32720 386-736-6622 d Quick Care M-F 9-5 New Urgent Medical Walk In Smyrna Care Treatment 317 S. Dixie AccepteVolusia Beach Center Centers, Inc. Freeway 32168 386-426-8600 d Florida Hospital Fish 1055 Saxon Volusia Orange City Hospital Memorial Blvd. 32763 386-851-5000 Florida Ormond Hospital- 264 S. Atlantic Volusia Beach Hospital Oceanside Avenue 32176 386-672-4161 Florida Hospital- Ormond Ormond 875 Sterthaus Volusia Beach Hospital Memorial Avenue 32174 386-676-6000 Halifax Medical Urgent Center Ormond Care Ormond 1688 W. Volusia Beach Center Beach Granada Blvd. 32174 386-615-4400 Halifax Urgent Medical 1041 Port Care Center Port Dunlawton Volusia Orange Center Orange Avenue 32127 386-767-4462

     Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 6 of 8

    Revised 7/10/05

Ritz Theater (usually North Florida Payroll)

    829 N. Davis St.

    Jacksonville, FL 32202

    Phone: 904-632-5555

First Aid Kit location: Kitchen area

    Security Office phone: Radio in Front Office

    Security Office location: Guards roam building no office

    Spectacor Management Group, Inc. SMG

    Contact: Deborah Johnson (within 24 hours) Expiration Date: 6/1/05 Phone: 630-0334 Phone: (312) 280-5600 Provider: Zurich Insurance Company Website: Policy Number: WC7913918 https://webc98ilaims.zurichna.com/mainpage.asEffective Date: 6/1/05 px

Times-Union Center for the Performing Arts - SMG

    1000 West Water Street Security Office phone: (904) 633-6112 (or by Jacksonville, FL 32202 radio) (904) 630-4000 Security Office location: Room 1165 by

     Symphony Office First Aid Kit location: Stagehand Office Notify Security and Manager-On-Duty as soon

    as possible Prime Osborn Convention Center - SMG

    1000 Water St. Security Office phone: (904) 630-4046 Jacksonville, Fl. 32204 Security Office location: Door 1, South end of Main Phone (904) 630-4000 building

     Notify Security and Manager-On-Duty as soon First Aid Kit location: Security Office as possible Alltel Stadium - SMG

    1145 E. Duval St. Security Office phone: (904) 633-6114 Jacksonville, Fl. 32202 Security Office location: Loading Dock, North Main Phone (904) 618-8005 end

     Notify Security and Manager-On-Duty as soon First Aid Kit location: _____________ as possible Jacksonville Veterans Memorial Arena - SMG

    300 A Philip Randolph Blvd. Security Office phone: (904) 630-3922 Jacksonville, FL 32202 Security Office location: Loading Dock, West Main Phone (904) 630-3900 end

     Notify Security and Manager-On-Duty as soon First Aid Kit location: Security Office as possible

     Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits. Thrasher-Horne Center for the Performing Arts (usually North Florida Payroll)

    283 College Drive Orange Park, FL 32065 First Aid Kit location: _____________ (904) 276-6815 Security Office phone: ____________

    Page 7 of 8

    Revised 7/10/05

Security Office location: _____________

    Hotel Venues

    Amelia Island Plantation

    6800 First Coast Hwy. (A1A) Security Office phone: (904) 277-5914 Amelia Island, FL 32034 Security Office location: Main Gate Main Phone (904) 261-6161 All security personnel certified in CPR and use Security Phone x 5242 of defibrillators. First Aid Kit location: Security Office and Security Roving Vehicle

    Hyatt (former Adams-Mark)

    225 E. Coastline Dr. Security Office phone: (904) 634-9095 x4560 Jacksonville, FL 32202 Security Office location: Rear of building, west of Main Phone (904) 633-9095 loading dock First Aid Kit location: Security Office

    Marriott Sawgrass

    1000 PGA Tour Blvd. First Aid Kit location: Security Office Ponte Vedra Beach, FL. 32082 Security Office phone: (904) 285-7777 x6704 Main Phone (904) 285-7777 Security Office location: Employee entrance Ritz-Carlton at Amelia Island

    4750 Amelia Island Parkway Security Office phone: (904) 277-1100 x1040 ndAmelia City, FL 32034 Security Office location: Employee entrance, 2 Main Phone (904) 277-1100 level parking garage First Aid Kit location: Security Office

    World Golf Village (usually North Florida Payroll)

    500 S. Legacy Trail First Aid Kit location: _____________ St. Augustine, FL. 32092 Security Office phone: (904) 940-4111 Main Phone (904) 940-8000 Security Office location: _____________

Decorating Companies - Allied/Brede, Arata, Freeman Decorating, GES, Shepherd

Decorating Company Supervisor will have workers comp info.

Failure to obtain medical treatment from a participating network provider, except in cases of emergency or urgently needed care, will jeopardize the employee’s workers’ compensation benefits.

    Page 8 of 8

    Revised 7/10/05

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