ACCIDENT REPORTING PROCEDURES
When
an injury (or alleged injury) occurs:
- See that the injured employee receives prompt medical attention, and complete the initial “Medical Treatment Authorization” form, including the “Drug/Alcohol Screen” section. The form is sent with the injured employee to the medical facility.
- Send the employee to an occupational accident medical facility.
Immediately upon notification of an incident:
-
Have the injured employee complete and sign the Employee Statement of Injury form.
- Have the employee sign the Medical Record Release Authorization.
- Complete the Supervisor’s Information Form.
- Complete a Witness Information Form.
Review the forms and make sure they are complete, signed and have your Company Name listed. MAKE COPIES OF THE ATTACHED FORMS FOR YOUR RECORDS AND FUTURE USE.
Immediately upon completion of the forms, fax OR email them to:
FAX: (972) 930-9479 or CLAIMS@FASTPA.COM
Accidents resulting in death or severe injury should be reported immediately by telephone. Call 972-930-9493 or Toll free 1-866-930-9493.
After FAS has received the completed notice and forms, you will be sent an acknowledgement letter. All medical bills should be submitted to FAS for approval and audit prior to payment.
If you should have any questions concerning a claim, do no hesitate to call us at
1-866-930-9493 between 8:00 A.M. and 5:00 P.M. Monday through Friday.
Entire Claims Kit
Download the the Claims Kit in its
entirety here (choose best format for
you):
Claims
Kit - Word
Document
Claims Kit
- PDF
Forms
include:
Employee Statement of Injury
Supervisor's Information Form
Witness Information Form
Medical Treatment Authorization
Physicians Report
Medical Records Release
Authorization
REVIEW FOR COMPLETENESS
FAX
OR
EMAIL
REPORT
NOTICES TO:
FAS
FAX: (972) 930-9479
Or
CLAIMS@FASTPA.COM
Should you have
any questions regarding any of these
forms, please contact our office at
(866) 930-9493 between 8:00 a.m. and
5:00 p.m., Monday through Friday.
Employee Statment of Injury
Employee Statement of Injury - Word Document
Employee Statement of Injury - PDF
Supervisor's Information Form
Supervisor's Information Form - Word Document
Supervisor's Information Form - PDF
Witness Information Form
Witness Information Form - Word Document
Witness Information Form - PDF
Medical Treatment Authorization
Medical Treatment Authorization Form - Word Document
Medical Treatment Authorization Form - PDF
Medical Records Release Authorization
Medical Records Release Authorization Form - Word Document
Medical Records Release Authorization Form - PDF