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Click here or scroll down to respond to this candidateRev. 7/25/23 LA First Notice PacketStreet Address Street Address
Lexington, KY Street Address -4875Phone: PHONE NUMBER AVAILABLEFax: PHONE NUMBER AVAILABLEMay Street Address , 2024ANGELA BROWN161 Blenche DriveAvondale, LA 70094Claim #: PHONE NUMBER AVAILABLEDate of Loss: 5/23/2024Insured: JEFFERSON PARISH SCHOOL BOARDRe: Employee: ANGELA BROWNWe recently received notice that you were injured at work. Broadspire, a Crawford Company, is a third party claims administration company. I will be the Broadspire claims representative that is assigned to adjust, investigate, and manage your workers compensation claim on behalf of JEFFERSON PARISH SCHOOL BOARD and the insurer noted below.In order to facilitate your care coordination timely, please provide any doctors and health care facilities with the following address so all bills and reports related to treatment for the job-related injury are forwarded to us for prompt review and consideration:BroadspirePO Box 14645Lexington, KY 40512If, by the time you receive this letter, we have not already spoken, please call me at the number below so we can discuss your claim in more detail.This letter contains important information regarding your workers compensation claim. Your help would be appreciated by completing the enclosed documents and returning them to us at your earliest convenience to: Broadspire c/o ConduentPO Box 14875Lexington, KY 40512-4875Employee's Report Physician Choice FormMedical Authorization Form Physician Request FormCertificate of ComplianceThank you for your cooperation.Sincerely,Broadspire Services, Inc. on behalf of:JEFFERSON PARISH SCHOOL BOARDBrandy L DriskillClaim ExaminerPHONE NUMBER AVAILABLEEmail: EMAIL AVAILABLE**MyClaim: This is Broadspires information and communication hub for injured workers. You can use it to view your claim information, access prescription medications, view check information (if applicable), look up a provider, contact your adjuster, or attach bills and other key documents to your record. You can find the MyClaim tool at myclaim.choosebroadspire.com or by scanning this QR code.** PHONE NUMBER AVAILABLERev. 3/6/14 Over-Spanish version Al dorso vea version en espaol. Employees Report attachmentJEFFERSON PARISH SCHOOL BOARDIMPORTANT Your employer has reported your injury to us. To assist us in giving prompt attention, please answer fully all questions on this report and mail it to us at once. EMPLOYEE'S REPORT Claim Number: PHONE NUMBER AVAILABLEFor whom were you working?What is your job?When were you hurt? Month Day Year A.M. P.M.Where did it occur?What were you doing?What happened? (answer fully)Please list the injuries sustained as a result of your on the job injury: Name and address of doctor treating you?Have you returned to work?If yes, on what date?Signature DateHome phone number SSN: XXXXXXXXX-001Rev. 3/6/14 Employees Report-SpanishJEFFERSON PARISH SCHOOL BOARDIMPORTANTE Su patrn nos ha reportado su lesin. Para ayudarnos en darle curso a la misma a la mentor brevedad, favor de responder en forma completa toda las preguntas en este informe y enviarnoslo inmediatamente a vuelta de correos.INFORME DEL EMPLEADO (REPORTE) Nmero de reclamo: PHONE NUMBER AVAILABLEPara quien trabajaba?Cul es su trabajo?Cuando se lesion? mes da ao AM/PMDonde ocurri?Que estaba haciendo?Que sucedio? (Responda en la forma ms completa.) Indique por favor las heridas sostenidas en consecuencia de su herida de trabajo:Nombre y direccin del mdico que le est tratando?Ha regresado a trabajar?Si ha regresado indique la fecha?Firma FechaNmero de telfono en su domicilio Su nmero de seguro social Direccin de correo electrnico NOTAR: En virtud de la seccin 23:1208.1, es un delito proporcionar en forma deliberada informacin falsa, incompleta o engaosa a cualquiera de las partes de una transaccin de indemnizacin por accidente laboral con el fin de cometer una estafa. Las sanciones pueden incluir reclusin en prisin, multas y prdida de beneficios de indemnizacin laboral. Claim number: PHONE NUMBER AVAILABLERev. 2/26/16 Release-MedicalattachmentAUTHORIZATION TO SHARE AND USE MEDICAL INFORMATION I allow all doctors, hospitals, other health care providers, government agencies, insurers, employers, schools, training facilities, health plans, policyholders, contract holders, vendors, health and benefit plan administrators or their successors ("Records Holders") to give out my medical information as explained on this form. This information includes, but is not limited to, any records or facts about my medical condition, treatment, supplies, employment, vocation, education training, income, and other insurance coverage including benefits paid ("Information"). I allow the Records Holders to give my Information to the following individuals or entities ("Benefit Managers"): the employer named below, Broadspire Services, Inc., their benefit plan or claims administrator(s), their related companies, contractors, investigators, attorneys, and service consultants, authorized union representatives, health care providers treating or evaluating me or my claim, and other individuals or entities involved in administering, evaluating, analyzing and managing the plan or my claim.I allow the Benefit Managers to use and give out the Information only to evaluate, analyze, manage and/or administer a claim for short term disability benefits, long term disability benefits, salary continuation, leave under the federal Family and Medical Leave Act, local and state leave laws, workers' compensation and/or any other health benefit program or leave benefit offered by and through my employer ("Benefits Program"). I also allow the Benefits Managers to give my Information to any other person or entity if needed to find out whether I am eligible for benefits, to manage my claim, or to run the Benefits Program. I expressly waive any and all rights that I may have to be notified of these communications. The Benefits Managers will tell those receiving the Information that the Information is confidential. I understand that once my Information is given out as allowed in this form, federal privacy laws may not protect it. I understand that this permission lasts twelve (12) months after my claim is processed or twelve (12) months after the end of my coverage under the Benefits Program, whichever is longer, unless law requires a shorter period. If I change my mind before that time, I can tell my Records Holders in writing that I do not want them to share any more information. If I tell them in writing to stop sharing information, it will not change any actions they took before I told them. If I do not sign this form, it will not affect how my health care providers treat me. However, if I do not sign, the Benefits Managers may not be able to review my claim and cannot find out whether I am eligible for benefits. This may result in denial of my request for benefits.The Information released under this authorization can be submitted to the Records Holders electronically, by phone or fax, or by mail. I know I can see or copy the records given to the Benefits Managers. I agree that a copy of this form may be treated as a signed original.Claimant's Name: ANGELA BROWN Birth Date: 9/24/1969 Date: Claimant's or Legal Representative's Signature Legal Representative's Name and Relationship Employer's Name: JEFFERSON PARISH SCHOOL BOARDNOTICE TO RECORDS HOLDERSThe Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. Genetic information as defined by GINA, includes an individuals family medical history, the results of an individuals or family members genetic tests, the fact that an individual or an individuals family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individuals family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services. State Web LA 1025EEattachmentState Web LA 1121attachmentPHONE NUMBER AVAILABLERev. 10/7/08 LA Notice of Proc for IMEattachmentNOTICE OF PROCEDURE FORINDEPENDENT MEDICAL EXAMINATIONLouisiana law requires us to advise you of the following: Should a dispute arise between you and your employer (or the employer's workers' compensation insurer) concerning your medical condition, you have a right to request that the Director of the Office of Workers' Compensation appoint a physician to conduct an independent medical examination. The report of this physician will be admitted into evidence at any later proceedings concerning your claim for workers' compensation benefits. Should you wish to have this physician appointed, you can either write to the Director at the following address: DirectorDepartment of LaborOffice of Workers' CompensationPost Office Box 94040Baton Rouge, LA 70804-9040or you can call the Office of Worker's Compensation at their toll free number: PHONE NUMBER AVAILABLEIt is unlawful for you to willfully make, or to assist or counsel someone to make a false statement or representation in order to obtain or to defeat workers' compensation benefits. If you violate this provision, you may be fined up to $10,000, imprisoned with or without hard labor for up to 10 years, or both, depending on the amount of benefits unlawfully obtained or defeated. In addition to these penalties, you may be assessed a civil penalty of up to $5,000.Rev. 2/11/14 Mileage Reimb Req FormattachmentWORKERS' COMPENSATION MILEAGE CLAIMNAME: ANGELA BROWN DATE OF INJURY: 5/23/2024HOME ADDRESS: SOCIAL SECURITY #:EMPLOYER:HOME TELEPHONE: INSURER'S CLAIM #: PHONE NUMBER AVAILABLENOTE: All mileage reimbursement is subject to the initial States jurisdictional guidelines in place for workers compensation. This includes the rate of reimbursement, actual miles traveled and the type of travel which can be reimbursed. Please utilize one line for travel to the medical provider, and a second line for travel from the medical provider to your actual destination (work, home, etc.). Full addresses are required and all mileage is verified prior to reimbursement.TRAVELDATEFROM ADDRESS(Home, doctor, hospital, etc)TO ADDRESS(Home, doctor, hospital, etc) MILESTOTALTOTAL MILES @ PER MILE = $NOTE: Under section 23:1208.1, 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 may include imprisonment, fines and forfeiture of workers compensation benefits. I certify that the above information furnished by me is true and correct, and based on such information, I hereby claim pay for the mileage as indicated.Signature Date***Please attach original parking receipts to this form for reimbursement. Please return to:Brandy Driskill, PO Box 14875, Lexington, KY 40512-4875 Or Fax to: (859) 550-2745Rev. 8/30/17 Physician Request No StmtattachmentEmployee: ANGELA BROWN Claim Number: PHONE NUMBER AVAILABLE Employer: JEFFERSON PARISH SCHOOL BOARD Date of Injury: 5/23/2024 Dear Injured Worker:Please list the names and addresses of all doctors, hospitals, and chiropractors you have received treatment from within the last five (5) years. Please include the name of your family doctor, any visits made to hospitals, clinics (even emergency visits), and the name of any other physicians or chiropractors you have seen. This information will help us to evaluate your claim to better serve your needs. Thank you for your cooperation in promptly completing and returning this information to us.YOUR FAMILY DOCTOR: ANY OTHER PHYSICIANS:1.HOSPITALS AND CLINICS: 2.1.3.2.4.3.5.CHIROPRACTORS:1.6.2.7.NOTE: Under section 23:1208.1, 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 may include imprisonment, fines and forfeiture of workers compensation benefits. |
