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IF AN INJURY OCCURS AT WORK, YOU MUST:
A. Report the accident immediately to your supervisor.
B. A physician chosen from the PANEL OF PHYSICIANS must be used if
medical treatment is needed.
C. If a panel physician is unavailable at the time of an emergency, an
emergency facility may treat you; however, any follow up care must be
rendered by the physician chosen by you from the Panel of Physicians.
D. Your Panel Physician can refer you to a specialist if needed. You may not
choose a specialist yourself.
E. As Virginia Law requires, (Section 65.2-603), enclosed is a Panel of
Physicians from which you must chose one as your treating physician. If
you do not receive treatment from a Panel Physician, your Workers'
Compensation benefits may be terminated and your medical bills will not
be paid. If you sustain a compensable work injury, your Workers'
Compensation Administrator will only be responsible for bills from the
following:
1. Panel Physicians
2. Authorized treating specialist
3. An emergency facility in a true emergency
v
1
STEP4 VRSA CompCare On-Call immediately notifies the medical facility if the injuredemployee is seeking treatment.CompCare On-Call inmediatamente notifica al centro médico si el empleado lesionado está por llegar y envia informes de incidente al empleador.amente al 9-1-1.
IMPORTANT: If the employee is unable or unwilling to call CompCare On-Call, the supervisor must call to report the injury.
IMPORTANTE: Por favor llame a CompCare On-Call ante de procurar tratamiento para emergencias ue no constituyan una amenaza a la vida y antes de abandonar el lugar de trabajo cuando sea posible.
www.vrsa.us | 800-963-6800
In the event of a Workplace Injury
En Caso De Una Lesión En ElLugar De Trabajo
STEPInjured employee immediately notifies supervisor of incident.Empleado lesionado notifica a su supervisor del incidente.
If this is a life or limb threatening injury, immediately dial 9-1-1.Si se trata de una lesion que amenaza la vida o una extremidad, llame inmediatamente al 9-1-1.
2STEPInjured employee immediately calls CompCare On-Call.Supervisor & empleado lesionado llamen inmediatamente a CompCare On-Call.
1-877-234-0898
STEP3 VRSA CompCare On-Call gathers pertinent information and advises the injuredemployee on appropriate care.CompCare On-Call recopila información pertinente y guia al empleado lesionado a atención adecuada.
Call 24-HoursLlame las 24-Horas
1-877-234-0898
CompCare On-Call Virginia Risk Sharing Association (VRSA) has partnered with S1 Medical to offer CompCare On-Call workers’
compensation nurse triage and reporting services.
All VRSA members have been enrolled for this service and are encouraged to participate in CompCare On-
Call, regardless of the number of workers’ compensation claims that are reported each year. The
assistance provided by an employer immediately following a work-related incident greatly determines the
outcome of a workers’ compensation claim (time lost from work, cost, etc.). With CompCare On-Call
employees have the opportunity to speak with a registered nurse (RN), immediately following the work-
related incident. The RN provides triage services and provides advice to the employee for appropriate
care.
The RN will also collect the information necessary to complete the state required Employer’s Accident
Report. Following the call with CompCare On-Call, an accident report will be sent to the member and
VRSA. If these services are utilized, the supervisor / member no longer needs to complete an Employer’s
Report of Injury, Quick Fax form, or report the claim on line to VRSA.
Nurse triage services have been successful in providing medical assistance to injured employees and
significantly reducing workers compensation costs. Members that have enrolled have experienced a
reduction in treatment due to home care recommendations where appropriate, panel of physicians being
utilized in lieu of emergency rooms, reduction in time employees are out of work, and significant
improvement in the lag time for reporting claims.
CompCare On-Call Services
VRSA dedicated toll-free number (1-877-234-0898). This number is for VRSA members only.
CompCare On-Call is available 24-7-365
Triage advice provided by a registered nurse
Nurse follow-up with injured employees who receive homecare advice
Immediate access to a registered nurse
CompCare On-Call will review the entire panel of physicians with the employee if the employee is
not provided a panel by the member. ***VRSA recommends that members provide the employee
with a copy of the panel of physicians prior to calling CompCare On-Call, when possible. Doing so,
makes the process easier for the employee and lessens the time the employee is on the phone.
Option available to report an injury only (without nurse intervention). This is available for
supervisors reporting injuries on the employee’s behalf, record only claims, employees that do not
wish to speak with a nurse, etc.
Injury reports sent via secure email
Wallet cards that include the member name and VRSA member number to ensure accuracy of
notification and claim set up
Members will be provided a monthly report of all claims reported.
Following the call, care instructions are sent via text to the employee when home care advice is
provided by the nurse
When treatment is recommended by the nurse and /or the employee plans to seek treatment, a
text is sent to the employee following the call, providing information regarding the physician the
employee selected from the panel (facility, address, and phone number)
A Provider Notice is faxed to the panel physician selected by the employee, notifying the medical
provider the employee is on the way for treatment. The provider notice includes CompCare On-
Call’s nurse triage notes and VRSA’s Medical First Report form. This form includes VRSA’s address,
telephone, and fax number for billing purposes. The medical provider will complete the Medical
First Report with the employee’s work status, fax it to VRSA, and return the report to the employee.
The employee will provide the completed report to their supervisor/employer, so the employer is
aware of the employee’s return to work capabilities or work restrictions.
The first fill prescription card is sent via text to employees that seek medical treatment.
Easy and efficient method for members to provide employee demographics to CompCare On-Call,
which reduces the time employees are on the phone providing this information and ensures
accuracy in reporting.
Coming Soon: A triage phone app for supervisors/managers to download. The app replaces the
need for carrying wallet cards; a supervisor may simply pull up the app and touch to call and report
an injury. Pictures of an injury may also be uploaded and sent to the nurse to better assist with
injuries.
Whitelist Domains to Receive Secure Emails
Injury reports will be sent via secure email to members. Registration and a password are not required to
view, print, and save these reports. To ensure receipt of the secure emails, please whitelist the following
secure email domains:
o S1-medical.com
o Triagenow.net
o Sendgrid.com
o Sendgrid.net
For additional information regarding CompCare On-Call visit our website: www.vrsa.us or contact Robin
Duvall, Director of Workers’ Compensation Claims by calling 1-800-963-6800, Ext. 7340 or via email at:
FOR ADDITIONAL ASSISTANCE WITH
WORKERS’ COMPENSATION MATTERS
PLEASE CONTACT:
Craig W. Smith
HR Coordinator
Office of Human Resources
Phone: (804) 693-7927
Fax: (804) 693-7886
Email: [email protected]
GLOUCESTER COUNTY SCHOOLS WORKER'S COMPENSATION PANEL OF PHYSICIANS
Rev. 2020-08
THE CLOSEST EMERGENCY FACILITY MAY BE USED IN AN EMERGENCY SITUATION. ONCE THE EMERGENCY TREATMENT IS COMPLETED A PANEL
PHYSICIAN MUST BE CHOSEN FOR FOLLOW UP CARE
___ I agree to select a doctor, if needed, from the below panel.
___ I have declined to select a physician from the below panel. I understand that I will have to pay for any medical treatment or doctor's bills, and that I will be denied workers' compensation for any absence based on a disability, which is not certified by an approved panel physician.
_______________________________________________ ___________________
Signature of Employee Date
_______________________________________________ ___________________ Signature of Supervisor Date
M.D. Express Urgent Care – Gloucester 6567 George Washington Memorial Highway | Gloucester, VA 23061 | 804-824-9962
Arakaky, Henry MD McKelvey, Kevin MD Purdy, Carol DO Cleary, Thomas MD Minneci, Peter MD Renforth, Michael MD Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Rizk, Alex MD Forest-Lam, James MD Newton, David MD Rosenberg, David DO Hoyt, Jennifer MD Obie, Eric MD Maulbetsch, Bruce DO Park, Chan MD
M.D. Express Urgent Care – Yorktown 4740 George Washington Memorial Highway Ste A | Yorktown, VA 23692 | 757-890-6339
Arakaky, Henry MD Minneci, Peter MD Purdy, Carol DO Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Renforth, Michael MD Gisanrin, Olu MD Newton, David MD Rizk, Alex MD Hoyt, Jennifer MD Obie, Eric MD Rosenberg, David DO LaBenne, Elisa MD Park, Chan MD Maulbetsch, Bruce DO
Akos Telemedicine -- Offered Through CompCare On-Call (VA) 877-234-0898
Gurrala, Joseph MD Teklu, Abraham MD Valle, Melanie Acevedo MD
GLOUCESTER COUNTY SCHOOLS WORKER'S COMPENSATION PANEL OF PHYSICIANS
Rev. 2020-08
Bon Secours Kilmarnock Primary Care -- Kilmarnock 402 North Main Street | Kilmarnock , VA 22482 | 804-435-2651
Ashworth, Joel MD Ashworth, Joel MD
Dr. Roxanne Dietzler, PC – Newport News 732 Thimble Shoals Blvd. Suite 102 | Newport News, VA 23606 | 757-599-3623
Dietzler, Roxanne DO
M.D. Express Urgent Care – Hampton 3321 West Mercury Blvd. | Hampton, VA 23666 | 757-224-0056
Cochran-Ward, Elizabeth MD Minneci, Peter MD Renforth, Michael MD Gisanrin, Olu MD Moors, William MD Rizk, Alex MD Hoyt, Jennifer MD Newton, David MD Jenkins-Haynie, Lisa MD Obie, Eric MD LaBenne, Elisa MD Park, Chan MD Maulbetsch, Bruce DO Purdy, Carol DO
M.D. Express Urgent Care – Newport News 12997 Warwick Blvd. | Newport News, VA 23602 | 757-369-9446
Arakaky, Henry MD Maulbetsch, Bruce DO Park, Chan MD Cochran-Ward, Elizabeth MD Minneci, Peter MD Purdy, Carol DO Gisanrin, Olu MD Mollenkopf, Holly MD Renforth, Michael MD Hoyt, Jennifer MD Newton, David MD Rizk, Alex MD Jenkins-Haynie, Lisa MD Obie, Eric MD Rosenberg, David DO LaBenne, Elisa MD
M.D. Express Urgent Care – Williamsburg 120 Monticello Ave | Williamsburg, VA 23185 | 757-564-3627
Arakaky, Henry MD Minneci, Peter MD Purdy, Carol DO Cochran-Ward, Elizabeth MD Mollenkopf, Holly MD Renforth, Michael MD Hoyt, Jennifer MD Newton, David MD Rizk, Alex MD LaBenne, Elisa MD Obie, Eric MD Rosenberg, David DO Maulbetsch, Bruce DO Park, Chan MD
GLOUCESTER COUNTY SCHOOLS SPECIALIST PANEL
Rev. 2020-08
HANDS TIDEWATER ORTHOPEDICS ASSOCIATES
4037 Ironbound Road | Williamsburg, VA | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA | 757-827-2480
Campolattaro, Robert MD
ORTHOPAEDIC ATLANTIC ORTHOPAEDIC SPECIALISTS
6160 Kempsville Circle Suite 200B | Norfolk, VA 23502 | 757-321-3386
Butkovich, Bradley MD Cohn, Sheldon MD Warren, Paul MD Byrd, J. Abbott III
ORTHOPAEDIC HAMPTON ROADS ORTHOPAEDICS & SPORTS MEDICINE
730 Thimble Shoals Boulevard, Suite 130 | Newport News, VA 23606 | 757-873-1554
Baddar, Adrian MD Cavazos, Daniel MD Swenson, Jon MD Carter, Anthony MD
ORTHOPAEDIC ORTHOPAEDIC AND SPINE CENTER (OSC)
250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900
Burow, John D. DO Carlson, Jeffrey MD
ORTHOPAEDIC RIVERSIDE ORTHOPEDIC SPECIALISTS
120 Kings Way Suite 2700 | Williamsburg, VA 23188 | 757-645-0145
Barley, IV John DO Kling, Scott R. MD
ORTHOPAEDIC TIDEWATER ORTHOPAEDICS ACCOCIATES
4037 Ironbound Road | Williamsburg, VA 23188 | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480
an- Higgins, Michael MD
GLOUCESTER COUNTY SCHOOLS SPECIALIST PANEL
Rev. 2020-08
ORTHOPAEDIC
VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS 2012 Meade Parkway | Suffolk, VA 23434 | 757-673-5680
Huttman, Daniel T. MD
ORTHOPAEDIC VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS
3300 High Street, Suite 1 | Portsmouth, VA 23707 | 757-673-5680 5838 Harborview Blvd. Suite 100 | Suffolk, VA 23434 | 757-673-5680
Blasdell, Steven MD Huttman, Daniel T. MD Marlow, Aaron MD
ORTHOPAEDIC – BACK & SPINE TIDEWATER ORTHOPAEDICS ASSOCIATES
4037 Ironbound Road | Williamsburg, VA 23188 | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480
an- Mason, Jonathan R. MD
ORTHOPAEDIC – BACK & SPINE VIRGINIA ORTHOPAEDIC & SPINE SPECIALISTS
MAST One Bldg., 1040 University Blvd. #200 | Portsmouth, VA 23707 | 757-673-5680
an- Kerner, Mark MD
ORTHOPAEDIC – FOOT & ANKLE ATLANTIC ORTHOPAEDIC SPECIALISTS
6160 Kempsville Circle Suite 200B | Norfolk, VA 23502 | 757-321-3386
an- Campbell, Michael MD
ORTHOPAEDIC – FOOT & ANKLE RIVERSIDE ORTHOPEDIC SPECIALISTS
120 Kings Way Suite 2700 | Williamsburg, VA 23188 | 757-645-0145
Vargo, Robin MD
GLOUCESTER COUNTY SCHOOLS SPECIALIST PANEL
Rev. 2020-08
ORTHOPAEDIC – HAND & UPPER EXTREMITY ATLANTIC ORTHOPAEDICS ASSOCIATES
6160 Kempsville Circle Suite 200B | Norfolk, VA 23502 | 757-321-3386
an- Manke, Chad MD
ORTHOPAEDIC – HAND & UPPER EXTREMITY TIDEWATER ORTHOPAEDICS ASSOCIATES
901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480
an- Smerlis, Nicholas MD
ORTHOPAEDIC – SHOULDER SURGERY HAMPTON ROADS ORTHOPAEDICS & SPORTS MEDICINE
730 Thimble Shoals Boulevard, Suite 130 | Newport News, VA 23606 | 757-873-1554
Fithian, Thomas MD
ORTHOPAEDIC – SHOULDER SURGERY ORTHOPAEDIC AND SPINE CENTER (OSC)
250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900 Coleman, Martin MD
ORTHOPAEDIC – SHOULDERS & KNEES ORTHOPAEDIC AND SPINE CENTER (OSC)
250 Nat Turner Boulevard | Newport News, VA 23606 | 757-596-1900 Haynes, III Boyd MD
ORTHOPAEDIC – SHOULDERS & KNEES TIDEWATER ORTHOPAEDICS ASSOCIATES
4037 Ironbound Road | Williamsburg, VA 23188 | 757-206-1004 901 Enterprise Parkway, Suite 900 | Hampton, VA 23666 | 757-827-2480
an- Payne, Loell MD Saban, Nicholas MD
Work Comp Medical First Report 1. To be completed by the treating physician - Please send completed forms to Virginia Risk Sharing Association
(VRSA) - fax 800-273-4865
2. Please provide the patient with a copy of the completed form.
3. Patient, provide your supervisor with a copy of this form after treating.
Patient’s Name: ____________________________________________________________________
Patient’s Address: ____________________________________________________________________
Name of Employer: ____Gloucester County Public Schools ________________________________
Date of Accident or Illness: ____/ ____/ ____
Patients account of How Injury or Exposure Occurred: _____________________________________________
_________________________________________________________________________________________
Name of Medical Facility: ___________________________________________________________________
Date of Visit: ____/ ____/ ____ Arrival Time: ___________ AM/PM Departure Time: ____________ AM/PM
Diagnosis: ___________________________________________________________________________
New Injury/Illness Existing Condition
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
Recommended Work Status:
A) May return to full duty beginning: ____/ ____/ ____
B) May return to modified duty beginning: ____/ ____/ ____
Recommendation based on:
______personal review of functional job description
______verbal description of job by employee/patient
______verbal description of job by employer representative
______other (describe:______________________________________________ )
The employee/patient is medically able to do the following activities:
_______________________________________________________________
_______________________________________________________________
Does condition preclude travel to and from work Yes No
Does condition preclude being at work Yes No
Anticipate return to full duty beginning: ____/ ____/ ____
C) Unable to work at this time
Anticipate return to modified duty beginning: ____/ ____/ ____
Anticipate return to full duty beginning: ____/ ____/ ____
Physician’s Comments (Please note any contributing factors, prior injuries and pre-existing conditions):
____________________________________________________________________________________________
____________________________________________________________________________________________
Follow-Up Appointment with: _______________________________ Date: ____/ ____/ ____ Time: __ ________ AM/PM
To ensure payment, any follow-up care must be authorized by Virginia Risk Sharing Association (VRSA)
Physician/Clinician Name (please print): _____________________________________Phone #_______________
Physician/Clinician Signature: ___________________________________________________________________
VRSA Billing Address: P. O. Box 182480, Columbus, OH 43218-2480 Tel.: 800-963-6800
Fax: 800-273-4865
Workers’ Compensation
First Fill Prescription Form Instructions
With this form, a 10 day supply of medication will be provided to the injured employee at no cost.
Instruct the injured employee to take this form to a network pharmacy and present this to the
pharmacy with their prescription(s).
The network includes all major chains (CVS, Rite Aid, Wal-Mart, K-Mart, Target, etc.) as well as most
of the medium and small local pharmacies. To view the pharmacy network or find a local pharmacy,
visit our pharmacy provider’s website at www.Aliushealth.com Click on the ‘Pharmacy Locator’ tab.
Once the claim is received and reviewed by Virginia Risk Sharing Association (VRSA), VRSA will let the
pharmacy provider know if the claim is accepted or denied. If accepted, the remaining supply of
medication will be filled. Any future prescriptions the injured employee needs will be direct billed
through the pharmacy provider. A pharmacy representative will also contact the injured employee
and explain the process. If the claim is denied, there is no financial consequence to the injured
employee for the first fill.
Important Information and Instructions for providing a first fill form to an injured employee:
This form is for workplace injuries only
A workers’ compensation claim must be reported to VRSA by calling CompCare On-Call,
nurse triage and reporting service: 1-877-234-0898
Before providing this form to the employee:
o Add the employee’s legal name
o Add the last 4 digits of the employee’s social security number to the Member ID:
ALIUSVRSA (for example: ALIUSVRSA1234).
o Add the date of injury
Provide this form to an employee immediately following the injury. Employees that do not
plan to seek treatment should not be provided this form.
This form is valid for one time use only. Do not provide an employee with additional
forms for the same injury. For additional medication beyond the first fill, the injured
employee must contact their VRSA claims representative: 1-800-963-6800.
Craig W. Smith
HR Coordinator
Office of Human Resources
Phone: (804) 693-7927
Fax: (804) 693-7886
Email: [email protected]
First Fill Instructions for VRSA Members
Dear Injured Worker, This is your temporary prescription card allowing up to a 10-day supply of medication at no cost. This card is for workplace incidents only and valid for one time use only.
Prior to presenting this card please add your first and last name, the last four digits of your social security number (SSN), and date of accident in the in the required fields. Present this card along with your prescription(s) to a participating pharmacy. Our extensive pharmacy network includes most major chains and many local pharmacies (some participating pharmacies are listed below). To view the pharmacy network or find a local pharmacy visit our website www.Aliushealth.com or call 844-661-4463.
Employee Name:
Member ID:
Add Last 4 Digits of patient’s SSN (Example: ALIUSVRSA1234)
RxGroup #: ALHFF08201701 RxBIN/IIN: 610729 RxPCN: ALIUS Person Code: 01 Date of Injury: ATTENTION PHARMACISTS: Please process prescriptions through Script Care.
For rejected claims, please call Alius Health at
844-661-4463. ATTENTION INJURED WORKER: The use of this
prescription card is restricted to your allowed injury
condition only. If the pharmacy staff advises that they are
unable to fill your medications due to a rejection, please
call 844-661-4463 for assistance.
*In some instances, an individual pharmacy may be removed from the network due to non-conformity
Walmart Kroger Target
Harris Teeter Wegmans Safeway
Sam’s club Food Lion CVS
Rite-Aid Costco Giant
Estimado Trabajador,
Alius Health es socio de VRSA a sido seleccionado para administrar su plan de medicamentos recetados para su lesiones.
Aquí esta su tarjeta de prescripción temporal que permite hasta 10 días de medicamento. Antes de presentar su tarjeta
porfavor ponga su nombre completo y los ultimos cuatro digitos de su securo social en el área indicada. Una vez que su
reclamación ha sido aceptada por VRSA se le enviara una tarjeta de reemplazo para requerir tratamiento continuo. La
tarjeta nueva le va a permitir medicamentos mensualmente relacionados a su lesion.
Nuestra extensa red de farmacias include las siguientes. Simplemente present esta tarjeta junto con su recetas a una
farmacia participantes. Para verificar si su farmacia preferida esta en nuestra red de farmacias puede utilizar nuestro
localizador de farmacia en www.Aliushealth.com o llamar 844-661-4463.
ALIUSVRSA