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 English- Word
Document
Claims Kit
English- PDF
Claims
Kit Spanish- Word
Document
Claims Kit
Spanish- PDF
Forms
include:
EMPLOYEE
STATEMENT OF INJURY
SUPERVISORS INCIDENT REPORT
WITNESS STATEMENT
MEDICAL TREATMENT AUTHORIZATION
PHYSICIAN’S REPORT OF EMPLOYEE INJURY
MEDICAL
RECORDS RELEASE AUTHORIZATION
DECLINE
MEDICAL TREATMENT
FORM
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
English:
Employee Statement of Injury - Word Document
Employee Statement of Injury - PDF
Spanish:
DECLARACIÓN DEL EMPLEADO DE LESIÓN - Word Doc
DECLARACIÓN DEL EMPLEADO DE LESIÓN - PDF
Supervisor's Information Form
English:
Supervisors Incident Report - Word Document
Supervisors Incident Report - PDF
Spanish:
INFORME DEL SUPERVISOR DE INCIDENTE - Word Doc
INFORME DEL SUPERVISOR DE INCIDENTE - PDF
Witness Information Form
English:
Witness Statement - Word Document
Witness Statement - PDF
Spanish:
DECLARACIÓN DE TESTIGO - Word Doc
DECLARACIÓN DE TESTIGO - PDF
Medical Treatment Authorization
English:
Medical Treatment Authorization - Word Document
Medical Treatment Authorization - PDF
Spanish:
AUTORIZACIÓN POR TRATAMIENTO MÉDICO Y - Word Doc
AUTORIZACIÓN POR TRATAMIENTO MÉDICO Y - PDF
Physicians Report of Employee Injury
English:
Physicians Report of Employee Injury - Word Document
Physicians Report of Employee Injury - PDF
Spanish:
INFORME DEL MÉDICO - Word Doc
INFORME DEL MÉDICO - PDF
Medical Records Release Authorization
English:
Medical Records Release Authorization - Word Doc
Medical Records Release Authorization - PDF
Spanish:
AUTORIZACIÓN PARA LA LIBERACIÓN DE REGISTROS MÉDICOS - Word Doc
AUTORIZACIÓN PARA LA LIBERACIÓN DE REGISTROS MÉDICOS - PDF
Decline Medical Treatment
English:
Decline Medical Treatment - Word Document
Decline Medical Treatment - PDF
Spanish:
Disminucion de TrataMiento Medico de Forma- Word Doc
Disminucion de TrataMiento Medico de Forma - PDF