Human Resource Department
Worker's Compensation Unit
Fax (860) 622-2927
Harlynn Jackson, HR Associate, (860) 262-6742, firstname.lastname@example.org Fax: (860) 730-8366
Betsy Riley, HR Associate (860) 262-6712, email@example.com
Injury Reporting Hotline: 1-800-828-2717
Workers’ Compensation Medical Treatment & New Initial Treatment Provider Network Guidelines
The State of Connecticut has an approved Managed Care Plan filed with the Connecticut Workers’ Compensation Commission. Under this plan, the State is required to pay for reasonable and necessary medical costs of a workplace injury or illness where services are rendered by an approved provider, with no charge to the employee.
DAS Statewide Workers’ Compensation Division in partnership with Gallagher Bassett and the Prime PPO Network is pleased to announce the roll out of a new initial treatment provider network effective July 1, 2017. We have aligned ourselves with occupational medical providers throughout the State to provide the best quality care and convenience for our employee’s workers’ compensation injuries. It is important to note that several State agencies and facilities already have identified an Initial Treatment Provider within the Workers’ Compensation network and within close proximity to them. Pursuant to Connecticut General Statute Sec. 31-294d entitled “Medical and surgical aid, Hospital ambulatory surgical center and nursing service” of the Workers’ Compensation Act: The employer is responsible for initial medical treatment at a designated office or facility. The injured employee is required to attend the initial visit with one of the designated initial treatment providers as identified by their employer. If the injured employee chooses not to visit the designated initial treatment provider or treats outside the Workers’ Compensation provider network, they may risk suspension of their benefits per order of the Workers’ Compensation Commission. The list of initial treatment providers is available at: http://ct.primehealthservices.com/Custom/CtIndex
The injured employee may choose an attending physician AFTER the initial visit from the State of CT Workers Compensation provider network. An injured employee whose employer does participate in an approved medical care plan must choose a physician from the list of doctors included in that plan.
If you have any questions, please contact your Agency Workers’ Compensation Liaison.
Forms for reporting a work related injury:
1. WC Injury Reporting Forms:
3. Miscellaneous WC Forms:
Mileage Worksheet to be completed for each medical appointment, including physical therapy. The mileage is for round trip travel to and from the appointment, either to and from home, or work. The completed form is sent directly to your Claims Adjuster at GAB Robins.
Verification of Medical Appointment Form
Verification of Medical Appointment to be completed for each medical appointment, including physical therapy, and either attached to the time sheet when the appointment occurred, or faxed directly to the DMHAS Workers' Compensation Unit. If the appointment occurs during work, you will be paid for this appointment thru payroll. If the appointment occurs after work, payment will be issued from GAB Robins. This form is not to be used during periods of disability.
Record of Employment Contact Form
Record of Employment Contact Form is to be used only when an employee is given a light duty work capacity, and the employer is unable to accommodate the restrictions, or find suitable work within the restrictions given. This form must be completed and submitted to GAB Robins in order to receive Temporary Partial benefits only.
4. Winter Safety Tips:
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