Freeman Administrative Solutions, Inc.

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

Employee Statment of Injury

Supervisor's Information Form

Witness Information Form

Medical Treatment Authorization

Physicians Report of Employee Injury

Medical Records Release Authorization

Decline Medical Treatment