Sedgwick Claims Kit Arkansas

Sedgwick Claims Kit
Arkansas
P.O. Box 14779 | Lexington, KY 40512 | Toll Free: 866-738-9201 | Fax: 859-280-3275
Dear Insured:
We would like to welcome you as a policyholder of Southern Insurance Company.
Sedgwick is your Claims Administrator and we are pleased to be able to provide you
with workers’ compensation claims handling services. Please follow the below
instructions for filing a new claim and note the claim kit attachment.
Where do I report a claim?
 Phone:
 Email:
 Fax:
855-728-5277 (855-7ATLAS7)
[email protected]
866-383-3296
Where do I send my injured employee for medical treatment?
 Website:
www.sedgwickproviders.com
Sedgwick Claim Kit Attachments:
Employer’s First Report of Injury Form (Form IA-1)
Employee’s Notice of Injury (Form AR-N)
Wage Statement – English & Spanish (Form AR-W)
Authorization for Release and Use of Medical Information
Frequently Asked Questions and Answers
Express Scripts First Fill Temporary Pharmacy Card
Need a loss run?
 Email us:
[email protected]
Have more questions?
Contact the Atlas Customer Care Team @ Sedgwick - One of our friendly Client Services
Associates will be happy to assist you.
 Phone:
866-738-9201
 Email:
[email protected]
We appreciate your business and believe that communication is critical for successful
claims administration. We encourage you to contact us if you have any questions.
www.Atlas.us.com/claims
CALIFORNIA Welcome Letter – Republic Underwriters Insurance Co. 7/2014
WORKERS COMPENSATION – FIRST REPORT OF INJURY OR ILLNESS
EMPLOYER (NAME & ADDRESS INCL ZIP)
CARRIER/ADMINISTRATOR CLAIM NUMBER
OSHA LOG CASE #
REPORT PURPOSE CODE
JURISDICTION
JURISDICTION CLAIM NUMBER
INSURED REPORT NUMBER
EMPLOYER’S LOCATION ADDRESS (IF DIFFERENT)
INDUSTRY CODE
LOCATION #
EMPLOYER FEIN
PHONE #
CARRIER/CLAIMS ADMINISTRATOR
CARRIER (NAME, ADDRESS, & PHONE #)
POLICY PERIOD
CLAIMS ADMINISTRATOR (NAME, ADDRESS & PHONE NO)
TO
CHECK IF APPROPRIATE
† SELF INSURANCE
CARRIER FEIN
POLICY/SELF-INSURED NUMBER
ADMINISTRATOR FEIN
EMPLOYEE/WAGE
NAME (LAST, FIRST, MIDDLE)
DATE OF BIRTH
SOCIAL SECURITY NUMBER
DATE HIRED
ADDRESS (INCL ZIP)
SEX
MARITAL STATUS
OCCUPATION/JOB TITLE
M
U
UNMARRIED
SINGLE/DIVORCED
EMPLOYMENT STATUS
M
S
K
MARRIED
SEPARATED
UNKNOWN
MALE
FEMALE
F
U UNKNOWN
# OF DEPENDENTS
PHONE
MONTH
DAY
WEEK
RATE
PER:
DAYS WORKED/WEEK
OTHER:
STATE OF HIRE
NCCI CLASS CODE
FULL PAY FOR DAY OF INJURY?
DID SALARY CONTINUE?
YES
YES
NO
NO
OCCURRENCE/TREATMENT
TIME EMPLOYEE
BEGAN WORK
AM
DATE OF INJURY/ILLNESS
PM
CONTACT NAME/PHONE NUMBER
TIME OF OCCURRENCE
AM
( ) CANNOT BE
DETERMINED
TYPE OF INJURY/ILLNESS
PM
LAST WORK DATE
DATE EMPLOYER
NOTIFIED
DATE DISABILITY
BEGAN
PART OF BODY AFFECTED
DID INJURY/ILLNESS/EXPOSURE OCCUR ON EMPLOYER’S
TYPE OF INJURY/ILLNESS CODE
PART OF BODY AFFECTED CODE
PREMISES?
YES
NO
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE
ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
OCCURRED
EXPOSURE OCCURRED
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR
ILLNESS EXPOSURE OCCURRED
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE
OCCURRED
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED
THE EMPLOYEE OR MADE THE EMPLOYEE ILL
CAUSE OF INJURY CODE
DATE RETURN(ED) TO WORK
IF FATAL, GIVE DATE OF DEATH
PHYSICIAN/HEALTH CARE PROVIDER (NAME & ADDRESS)
WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED?
WERE THEY USED?
HOSPITAL OR OFF SITE TREATMENT (NAME & ADDRESS)
YES
NO
NO
YES
INITIAL TREATMENT
0
NO MEDICAL TREATMENT
1
MINOR: BY EMPLOYER
2
MINOR CLINIC/HOSP
3
EMERGENCY CARE
4
HOSPITALIZED > 24 HOURS
5
FUTURE MAJOR MEDICAL/
LOST TIME ANTICIPATED
OTHER
WITNESSES (NAME & PHONE #)
DATE ADMINISTRATOR NOTIFIED
FORM IA-1(r 1-1-02)
DATE PREPARED
PREPARER’S NAME & TITLE
SEE BACK FOR IMPORTANT INFORMATION
PHONE NUMBER
IAIABC 2002
AWCC Form 1
(Employer's First Report of Injury or Illness)
Ark. Code Ann. § 11-9-529 allows employers 10 days to report injuries. Those involving
either more than 7 days of lost time or indemnity payments require Form 1. Also, a Form 1 is
required for all controversions including a medical-only case. Self-insured employers file Form 1
with the AWCC; other employers send it to their insurance representatives.
Employers do NOT fill in the shaded areas.
On Form 1, employers/carriers must:
1.
In the Occurrence Section list the date the employer first knew of the injury. The 10
days to report begin either on the date of disability or the date the employer was
notified, whichever date is later.
2.
Give the name of the carrier. An insurance agency or third party administrator should
be listed in the Preparer's Section. A carrier can pre-print its name and address in the
Carrier Section to help clients properly report.
3.
Specify the carrier Federal Employer Identification Number (FEIN) in the Carrier
Section.
4.
Type or print in ink. An illegible, incomplete Form 1 will be returned.
Neglect of Form 1: Late employee benefits, exposing employers to fines.
Lack of Form 1: Delays in insurance investigation.
General inquiries on Form 1 can be answered by the AW CC Supp ort Ser vices Division.
Questions on a specific Form 1 may be directed to the Research and Statistics Section, which processes
the accident reports. (1-800-6 22-447 2 or 501 -682-393 0).
Ark. Code Ann. §11-9-10 6(a): “Any p erson or entity who willfully and kno wingly make s any m aterial false
statement or representation, who willfully and knowingly omits or conceals any material information, or who
willfully and knowingly employs any device, sche me, or artifice for the purpose of: obtaining any benefit or
paym ent; defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining
or avoiding workers’ compensation coverage or avoiding payment of the proper insurance premium, or who aids
and abets for any of said p urposes, und er this chapter shall be guilty of a Class D felo ny. Fifty percent (50%) of
any criminal fine imposed an d collected under .... this section shall be paid and allocated in accord ance with
app licable law to the Death and Permanent Total Disability Trust Fund administered by the Workers’ Compensation
Commission.”
(Revised 1-1-2001)
EMPLOYER’S INSTRUCTIONS
DO NOT ENTER DATA IN SHADED FIELDS
DATES:
Enter all dates in MM/DD/YY format.
INDUSTRY CODE:
This is the code which represents the nature of the employer’s business, which is contained in the Standard
Industrial Classification Manual or the North American Industry Classification System, published by the Federal
Office of Management and Budget.
CARRIER:
The licensed business entity issuing a contract of insurance and assuming financial responsibility on behalf of
the employer of the claimant.
CLAIMS ADMINISTRATOR:
Enter the name of the carrier, third party administrator, state fund, or self-insured responsible for administering
the claim.
AGENT NAME & CODE NUMBER:
Enter the name of your insurance agent and his/her code number if known. This information can be found on
your insurance policy.
OCCUPATION/JOB TITLE:
This is the primary occupation of the claimant at the time of the accident or exposure.
EMPLOYMENT STATUS:
Indicate the employee’s work status. The valid choices are:
Full-Time
On Strike
Unknown
Part-Time
Disabled
Apprenticeship Full-Time
Not Employed
Retired
Apprenticeship Part-Time
Volunteer
Seasonal
Piece Worker
DATE DISABILITY BEGAN:
The first day on which the claimant originally lost time from work due to the occupation injury or disease
or as otherwise designated by statute.
CONTACT NAME/PHONE NUMBER:
Enter the name of the individual at the employer’s premises to be contacted for additional information.
TYPE OF INJURY/ILLNESS:
Briefly describe the nature of the injury or illness, (eg. Lacerations to the forearm).
PART OF BODY AFFECTED:
Indicate the part of body affected by the injury/illness, (eg. Right forearm, lower back).
DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
(eg. Maintenance Department or Client’s office at 452 Monroe St., Washington, DC 26210)
If the accident or illness exposure did not occur on the employer’s premises, enter address or location.
Be specific.
FORM IA-1(r 1-1-02)
IAIABC 2002
EMPLOYER’S INSTRUCTIONS – cont’d
ALL EQUIPMENT, MATERIAL OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS
EXPOSURE OCCURRED:
(eg. Acetylene cutting torch, metal plate)
List all of the equipment, materials, and/or chemicals the employee was using, applying, handling or operating
when the injury or illness occurred. Be specific, for example: decorator’s scaffolding, electric sander,
paintbrush, and paint.
Enter “NA” for not applicable if no equipment, materials, or chemicals were being used. NOTE: The items listed
do not have to be directly involved in the employee’s injury or illness.
SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE
OCCURRED:
(eg. Cutting metal plate for flooring)
Describe the specific activity the employee was engaged in when the accident or illness exposure occurred,
such as sanding ceiling woodwork in preparation for painting.
WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED:
Describe the work process the employee was engaged in when the accident or illness exposure occurred, such
as building maintenance. Enter “NA” for not applicable if employee was not engaged in a work process (eg.
walking along a hallway).
HOW INJURY OR ILLNESS/ABNORMAL HEALTH CONDITION OCCURRED. DESCRIBE THE SEQUENCE OF
EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT DIRECTLY INJURED THE EMPLOYEE OR MADE
THE EMPLOYEE ILL:
(Worker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against
the hot metal.)
Describe how the injury or illness/abnormal health condition occurred. Include the sequence of events and
name any objects or substance that directly injured the employee or made the employee ill. For example:
Worker stepped to the edge of the scaffolding to inspect work, lost balance and fell six feet to the floor. The
worker’s right wrist was broken in the fall.
DATE RETURN(ED) TO WORK:
Enter the date following to most recent disability period on which the employee returned to work.
FORM IA-1(r 1-1-02)
IAIABC 2002
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form AR-N
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
Ark. Code Ann.
§§11-9-701, 508, 514
AWCC Rule 099.33
Revised: 1-1-200 1
Updated: 8 -1-2006
N
EMPLOYEE’S NOTICE OF INJURY
EMPLOYEE INFORMATION (Please Print in Ink)
Employee’s Last Name
First Name
Street Address or P.O. Box
Child Support Obligation:
MI
Social Security Number
City
Current
Past Due
Home Phone No.
State
Zip Code
Payable to:
EMPLOYER INFORMATION (Please Print)
Employer’s Name
Employer’s Street Address or P.O. Box
Supervisor’s Name
Employer’s City
State
Zip Code
ACCIDENT INFORMATION (Please Print)
Date
Place of Accident
Date of Accident
Time of Accident
/Time
Employer Notified of Accident
What part of your body was injured?
Briefly discuss the cause of injury:
Name/address of witness(es):
I hereby authorize any hospital, physician, psychotherapist or practitioner of the healing arts to furnish the bearer any information, written or oral,
including, but not limited to, copies of medical records concerning my past, present or future physical, mental or emotional condition. I hereby waive
my physician- and psychotherapist-patient privilege. A photostatic copy of this authorization shall be as effective and valid as the original. My signature
below also indicates that I have been provided with my rights regarding change-of-physician. (See additional information on back side of form)
Date
Signature
Assistance with AWCC Form N is available from the AWCC Legal Advisor Division (1-800-250-2511 or 501-682-3930). Information is supplied
by the Support Services Division (1-800-622-4472 or 501-682-3930).
Ark. Code Ann §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statement or representation, who willfully and knowingly
omits or conceals any material information, or who willfully and knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment;
defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’ compensation coverage or avoiding
payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any
criminal fine imposed and collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent Total Disability
Trust Fund administered by the Workers’ Compensation Commission.”
Front side / Two-sided Form
N
ARKANSAS WORKERS’ COMPENSATION COMMISSION
Form AR-N
Ark. Code Ann.
§§ 11-9-701, 508, 514
AWCC Rule 33
Revised: 1-1-2001
Updated: 8-1-2006
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
N
EMPLOYER’S NOTICE TO EMPLOYEE
NOTICE TO EMPLOYEE - Fill out this form to give to your employer immediately. Employer: Be sure the
employee receives a copy of this form [Ark. Code Ann. § 11-9--514 (c)]
Ark. Code Ann. § 11-9-701. Notice of injury or death.
(a)(1)
(2)
(3)
(b)(1)
(2)
Unless an injury either renders the employee physically or mentally unable to do so, or is made known to the employer immediately after
it occurs, the employee shall report the injury to the employer on a form prescribed or approved by the Workers’ Compensation
Commission and to a person or at a place specified by the employer, and the employer shall not be responsible for disability, medical,
or other benefits prior to receipt of the employee’s report of injury.
All reporting procedures specified by the employer must be reasonable and shall afford each employee reasonable notice of the
reporting requirements.
The foregoing shall not apply when an employee requires emergency medical treatment outside the employer’s normal business hours;
however, in that event, the employee shall cause a report of the injury to be made to the employer on the employer’s next regular
business day.
Failure to give the notice shall not bar any claim:
(A) If the employer had knowledge of the injury or death;
(B) If the employee had no knowledge that the condition or disease arose out of and in the course of the employment; or
(C) If the commission excuses the failure on the grounds that for some satisfactory reason the notice could not be given.
Objection to failure to give notice must be made at or before the first hearing on the claim.
CHOICE/CHANGE OF PHYSICIAN
Rights and responsibilities. Treatment or services furnished or prescribed by any physician other than the ones selected according to the provisions
below, except emergency treatment, shall be at the claimant’s/employee’s expense.
Ark. Code Ann. § 11-9-508. Medical services and supplies.
“(e). . . [T]he injured employee shall have direct access to any optometric or ophthalmologic medical service provider who agrees to provide
services under the rules, terms, and conditions regarding services performed by the managed care entity initially chosen by the employer for the
treatment and management of eye injuries or conditions.”
1. Your employer shall have the right to select the initial primary care physician from among those associated with certified MCOs.
2. You may request a change-of-physician. You should initially request a change from the insurance carrier or employer. Within five business days of
your initial request for a change-of-physician, the insurance carrier or employer should notify you of its decision to grant or deny the change-of-physician.
3. If your request for change of physician is denied you may send a petition to the Clerk of the Arkansas Workers’ Compensation Commission for a one
(1) time only change-of-physician.
4. If your employer has contracted with a certified MCO, you shall be allowed to change physicians by petitioning the commission one (1) time only
for a change-of-physician to a physician who must also either be associated with the certified MCO chosen by your employer or who is your regular
treating physician. (Your “regular treating physician” is one who maintains your medical records and with whom you have a history of regular treatment before
the onset of your compensable injury.) The health care provider to whom you change must agree to refer you to the certified MCO chosen by your employer
for any specialized treatment, including physical therapy, and must agree to comply with all the rules, terms, and conditions regarding services performed by
the MCO initially chosen by your employer.
5. If your employer does not have a contract with a certified MCO, you shall be allowed to change physicians by petitioning the commission one (1)
time only for a change-of-physician to a physician who must either be associated with any certified MCO or who is your regular treating physician. (See
definition above.) The health care provider to whom you change must agree to refer you to a physician associated with any certified MCO for any specialized
treatment, including physical therapy, and must agree to comply with all the rules, terms, and conditions regarding services performed by any certified MCO.
Back side / Two-sided Form
N
ARKANSAS WORKERS’ COMPENSATION COMMISSION
324 Spring Street, Little Rock, AR 72201
Mail: P. O. Box 950, Little Rock, AR 72203-0950
501-682-3930 / 1-800-622-4472
Form AR -W
Authority: Ark. Code Ann.
§11-9-518 Revised: 1-1-2001
W
WAGE STATEMENT IMMEDIATELY PRECEDING INJURY DATE
Weeks
Straight Time
Worked
Days
Hours
Wages Paid For
Straight Time
Overtime Hours
Worked
Days
Wages Paid for
Overtine
AWCC No.
Hours
1
2
Carrier Claim No.
3
4
5
Employee Name:
6
7
8
9
10
Employee S.S.No.:
11
12
13
14
Employer Name:
15
16
17
18
Employer FEIN No.:
19
20
21
22
Carrier or Self-Insured Name:
23
24
25
26
Carrier NAIC No.:
27
28
29
30
31
32
33
34
35
INSTRUCTIONS FOR
COMPLETING WAGE STATEMENT
(To be completed only if claimant
receives less than maximum b enefits)
36
37
38
39
40
41
In completing the W age Statement, in week
one give information for the week pr ior to
the injury and follow with preceding w eeks.
Days and hours of straight time wor k should
be given in all cases.
42
43
Explanation of time lost by employee:
44
45
46
47
48
49
50
51
52
Total
w
AWCC Form W
(Wage Statemen t)
1. The AWC C Advisory 88-1 requires respondents to file Form W (w ith the A W CC file number for the case,
obtained from AWCC Form A-110) if the claimant receives less than the maximum compensation rate.
2. The average weekly wage of the injured worker shall "[I]n no case...be computed on less than a full-time
workweek in the em ployment." [Ark . Code An n. § 11-9-518(a)(1)]
Informa tion on F orm W is availab le from th e Office S ervices Se ction. Ge neral Info rmation is
available from the Support Services Division. (1-800-622-4472 or 501-682-3930)
Ark. Code Ann. §11-9-106(a): “Any person or entity who willfully and knowingly makes any material false statement
or representation, who willfully and knowingly omits or conceals any material information, or who willfully and
knowingly employs any device, scheme, or artifice for the purpose of: obtaining any benefit or payment; defeating or
wrongfully increasing or wrongfully decreasing any claim for benefit or payment; or obtaining or avoiding workers’
compensation coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said
purposes, under this chapter shall be guilty of a Class D felony. Fifty percent (50%) of any criminal fine imposed and
collected under .... this section shall be paid and allocated in accordance with applicable law to the Death and Permanent
Total Disability Trust Fund administered by the Workers’ Compensation Commission.”
AUTHORIZATION FOR RELEASE AND USE OF MEDICAL INFORMATION
I authorize each of the parties identified below to use and disclose any and all of my individually identifiable medical or health information, as
described below, for purposes of administering my claim or request for reasonable accommodation. I understand that the information about me that I
authorize to be used or disclosed may be redisclosed in accordance with the terms of this Authorization by the recipient thereof and may no longer be
protected by federal or state privacy laws or regulations.
I specifically authorize physicians, nurses and hospitals to communicate my individually identifiable medical or health information by any means,
including written or telephonic communications or by direct interview, whether or not I am present during, or notified of, such communications, and I
hereby authorize Sedgwick Claims Management Services, Inc. ("Sedgwick") to initiate and conduct such communications whether or not I am present
or have received notice thereof.
1.
What Information is covered by this Authorization? This authorization applies to all medical, health, psychological, and/or psychiatric
information, records and reports, including information regarding pre-existing health or medical conditions or illnesses (a) that are in
existence while this authorization is valid (see Item 3) and (b) that are related to any of the following: my request for reasonable
accommodation; my workers’ compensation claim; my claim for disability benefits; my claim for bodily injury; my claim for personal injury;
my claim for FMLA or my claim for dental benefits.
My claim or request for reasonable accommodation involves the following condition:
My information to be disclosed may include, but is not limited to, medical or health history, chart notes, prescriptions, diagnostic test results,
x-ray reports, and records received from other health care providers. If directly related to my claimed condition or illness, this information
may include the following, Please check yes or no and initial:
HIV test results, HIV or AIDS information.
YES
NO
Initial here
Psychiatric information.
YES
NO
Initial here
Information related to drug or alcohol abuse.
YES
NO
Initial here
The 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 individual’s family medical history, the results of an individual’s or family member’s
genetic tests, the fact that an individual or an individual’s family member sought or received genetic services, and genetic information of a
fetus carried by an individual or an individual’s family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
2.
Who may disclose and receive Information under this Authorization?
A. Any person or facility that attends, treats or examines me, including but not limited to
(specific name, if needed) is to make this information
available to Sedgwick or any of its agents, representatives or independent contractors; and
B.
When relevant to my claim, Sedgwick may re-disclose (without my further authorization) any and all of my individually identifiable
medical or health information (whether obtained pursuant to this authorization or otherwise from any person or entity) to any of the
following, (a) Any person or facility that attends, treats or examines me; (b) Any person or facility that impacts determination of my
claim or that coordinates my benefits; (c) My employer and its affiliates and their representatives, independent contractors and
service providers that may receive any such information from my employer to the extent permitted by state or federal law; or
(d) The Social Security Administration or a social security or vocational rehabilitation vendor. Sedgwick may use my information
obtained pursuant to this authorization in any other claim matter that Sedgwick may administer or handle related to me.
3.
How Long this Authorization is Valid? This authorization is valid during the duration of my claim(s) and any future related claims, unless a
different period is required under applicable federal or state law.
4.
Revocation of this Authorization. Unless otherwise provided by federal or state law, I understand that I may revoke this authorization at
any time by notifying, in writing, Sedgwick at
of my revocation and that my revocation shall be effective upon Sedgwick
receipt of my notice of revocation. I also understand that my revocation of this Authorization will not have any effect on any actions taken
by Sedgwick before its receives my revocation.
5.
Processing of Claims. I understand that this Authorization is generally necessary for the processing of my claim or request for reasonable
accommodation. Failure to sign this Authorization may impair or impede the processing of my claim or request for reasonable
accommodation.
1
6.
Refusal To Sign. I further understand my health care providers will not condition my treatment, payment, enrollment or eligibility on my
refusal to sign this Authorization.
I understand that I have the right to request and receive a copy of this authorization. I understand that I have the right to inspect the disclosed
information at any time. A photocopy of this authorization shall be valid and is to be accepted with the same effect as the original.
Signature of Patient or Patient’s Representative
Patient’s Address
Printed Name of Patient or Patient’s Representative
Patient’s Social Security Number
Representative’s Relationship to Patient, if applicable
First Day Absent
Date Signed
Date of Birth
Sedgwick 7/2013
Sedgwick Claims Management Services, Inc.
NOTICE OF STATE FRAUD REQUIREMENTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Any person or entity who willfully and
knowingly makes any material false statement or representation, or who willfully and knowingly omits or conceals any material information, or
who willfully and knowingly employs any device, scheme or artifice, for the purpose of obtaining any benefit or payment, or for the purpose of
defeating or wrongfully increasing or wrongfully decreasing any claim for benefit or payment or obtaining or avoiding workers compensation
coverage or avoiding payment of the proper insurance premium, or who aids and abets for any of said purposes, under this chapter shall be guilty
of a Class D felony.
2
AUTORIZACIÓN PARA USO Y DIVULGACIÓN DE INFORMACIÓN MÉDICA
Yo, autorizo a cada una de las partes identificadas a continuación, para usar y divulgar cualquier y toda información médica y de salud inidentificable
individualmente como mía, como se describe más adelante, para propósitos de administración de mi solicitud o petición para un acomodo razonable.
Entiendo que la información sobre mí, que yo autorizo para uso y divulgación, puede estar sujeta a divulgación posterior, de acuerdo con los términos
de esta Autorización, por parte del destinatario de ésta y que es posible que ya no esté protegida por las leyes y regulaciones federales o del estado sobre
privacidad.
Autorizo, específicamente, a médicos, enfermeras y hospitales para comunicar la información de salud o médica identificable individualmente como
mía, a través de cualquier medio, incluidas comunicaciones escritas o telefónicas, o por entrevista directa, sea que este presente o se me haya notificado
o no, de dichas comunicaciones, y por la presente, autorizo a Sedgwick Claims Management Services, Inc. ("Sedgwick") para iniciar y realizar dichas
comunicaciones, sea que este presente o haya recibido notificación de esto o no.
1. ¿Qué información está incluida en esta Autorización? Esta autorización se aplica a toda la información, registros e informes
médicos, de salud, sicológicos y/o psiquiátricos, incluida información sobre condiciones o enfermedades médicas o de salud pre-existentes
(a) que estén en existencia durante la validez de esta autorización (ver Punto 3) y (b) que estén relacionadas con cualquiera de las siguientes
solicitudes: mi solicitud de acomodo razonable, mi solicitud de compensación del trabajador; mi solicitud de prestación por invalidez, mi
solicitud por lesión corporal, mi solicitud por accidentes personales, mi solicitud de FMLA o mi solicitud de prestaciones dentales.
Mi solicitud o petición para acomodo razonable involucra las siguientes condiciones:
Mi información, que será divulgada, puede incluir, pero no se limita a, historia médica o de salud registros médicos, prescripciones, resultados
de evaluaciones de diagnóstico, informes de rayos X y registros recibidos de otros prestadores de salud. Esta información puede incluir lo
siguiente, si está directamente relacionada con las condiciones o enfermedades demandadas. Por favor, marque sí o no e inicial:
resultados de pruebas de VIH, información sobre VIH o
SIDA
SÍ
NO
Inicial aquí
Información siquiátrica.
SÍ
NO
Inicial aquí
Información relacionada con abuso de drogas o alcohol.
SÍ
NO
Inicial aquí
La Ley contra la discriminación de información genética de 2008 (GINA, por sus siglas en inglés) prohíbe a los empleadores y otras entidades
que abarca el Título II de la GINA solicitar o requerir información genética de un individuo o miembro de la familia del individuo, excepto en
los casos específicamente permitidos por esta ley. Para cumplir con esta ley, le solicitamos no brindar ninguna información genética cuando
responda a esta solicitud de información médica. “Información genética”, como lo define la GINA, incluye la historia médica de la familia de
un individuo, los resultados de pruebas genéticas del individuo o la de un miembro de su familia, el hecho de que un individuo o un miembro
de la familia del individuo buscó o recibió servicio genéticos e información genética de un feto que el individuo o un miembro de la familia
del individuo está gestando o un embrión en el vientre legalmente en el individuo o un miembro de la familia del individuo que recibe
servicios reproductivos de asistencia.
2. ¿Quién puede divulgar y recibir información bajo esta Autorización?
A. Cualquier persona o entidad que me atienda, trate o examine, incluida, pero no
limitada a
(nombre específico, si es necesario) para poner esta
información
a disposición de Sedgwick o cualquiera de sus funcionarios, representantes o contratistas independientes; y
B.
Cuando sea pertinente a mi solicitud, Sedgwick puede divulgar posteriormente (sin autorización ulterior) cualquier o toda información
médica o de salud identificada individualmente como mía (fuese obtenida de acuerdo con esta autorización o, de lo contrario, de otra
persona o entidad) a cualquiera de los siguientes: (a) cualquier persona o institución que me atienda, trate o examine; (b) cualquier
persona o institución que influya en la determinación de mi solicitud o que coordine mis beneficios; (c) mi empleador y sus afiliados y
sus representantes, contratistas independientes y prestadores de servicios que puedan recibir tal información de mi empleador hasta al
grado que permite la ley federal o estatal, o (d) la Dirección del Seguro Social o el proveedor de seguro social o rehabilitación
vocacional. Sedgwick puede usar mi información, obtenida de acuerdo con esta autorización, en cualquier otra materia de solicitud que
Sedgwick pueda administrar o manejar en relación a mí.
3.
¿Por cuánto tiempo es válida esta Autorización? Esta autorización es válida por el período de duración de mi(s) petición(es) y de cualquier
petición relacionada futura; a menos que se requiera un período diferente de acuerdo con la ley federal o estatal correspondiente.
4.
Revocación de esta Autorización. A menos que la ley federal o estatal establezca otra cosa, entiendo que puedo revocar esta autorización
en cualquier momento al notificar, por escrito, a Sedgwick a_________ de mi revocación y que ésta entrará en efecto una vez que Sedgwick
haya recibido mi notificación de revocación. También entiendo que mi revocación de esta Autorización no tendrá ningún efecto sobre las
acciones tomadas por Sedgwick antes del recibo de mi revocación.
3
5.
Procesamiento de una Solicitud. Entiendo que esta Autorización, generalmente, es necesaria para el procesamiento de una solicitud o
petición de acomodo razonable. El no firmar esta autorización puede perjudicar o impedir el procesamiento de mi solicitud o petición de
acomodo razonable.
6.
Denegación de Firma Además, entiendo que mis prestadores de atención médica no condicionarán mi tratamiento, pago, inscripción o
elegibilidad, en caso de negarme a firmar esta Autorización.
Entiendo que tengo derecho a solicitar y recibir una copia de esta autorización. Entiendo que tengo derecho de inspeccionar la información
divulgada en cualquier momento. Una fotocopia de esta autorización será válida y aceptada con el mismo efecto que el original.
Firma del Paciente o Su Representante
Dirección del Paciente:
Nombre del Paciente o Su Representante
Número del Seguro Social del Paciente
Parentesco del
corresponde
Representante
con
el
Paciente,
si
Primer Día Ausente
Día de Firma
Fecha de Nacimiento
Sedgwick Claims Management Services, Inc.
Sedgwick 7/2013
AVISO DE REQUISITOS DE FRAUDE ESTATAL
Cualquier persona que a sabiendas presente una reclamación falsa o fraudulenta para el pago de una pérdida o beneficio, o que a sabiendas
presente información falsa en una solicitud de seguro es culpable de un crimen y puede estar sujeta a multas y encarcelamiento. Cualquier
persona o entidad que intencionadamente y a sabiendas haga alguna declaración o representación material falsa o que intencionadamente y a
sabiendas omita u oculte alguna información material o que intencionadamente y a sabiendas emplee algún dispositivo, ardid o artificio con el
propósito de obtener algún beneficio o pago, o con el propósito de aumentar o disminuir erróneamente o rechazar alguna reclamación de
beneficios o pago u obtener o evitar la cobertura de la indemnización laboral o evitar el pago de la prima de seguro apropiada o que instigue a
alguien con cualquiera de los propósitos mencionados, será culpable de un delito grave de Clase D bajo este capítulo.
4
Arkansas Workers’ Compensation
Questions & Answers
What is Workers' Compensation?
Ark ans as' no-fault com pen sation law was c reate d by an initiated ac t in 1939 to guara ntee prom pt,
automatic benefits to workers injured on the job. Before the W orkers' Com pensation Law, an injured
worker had to sue the employer to recover medical costs and lost wages. Lawsuits took m onths and
sometimes years. Juries and judges had to decide who was at fault and how much, if anything, would be
paid. It was a costly, time consum ing and unfair system.
If an employee is unable to work because of a job injury, the employer’s workers' compensation
policy tak es c are o f the m edical exp ens es a nd p ays the em ployee m one y to live on until he/sh e is ab le to
go back to work. In most cases, these benefits are started automatically, without delay or red tape.
Effective July 1, 1993, reform legislation was enacted and Act 796 of 1993 became the law for
wo rkers' com pensatio n claim s. T he follo wing questio ns and answe rs concern injuries occurring after July
1, 1993.
Who is covered?
Almost every working Arkansan is protected by the W orkers' Com pensation Law, but there are a
few exceptions. Businesses where there are two or fewer employees may not be covered. Railroad and
maritime workers are covered by federal laws. The Arkansas W orkers' Com pensation Law does not
apply to employment of agricultural farm labor, domestic help, or employment by non-profit, religious,
charitable or relief organizations. Also exempt from the law are personnel covered exclusively by federal
law.
How do I know if my employer has workers' compensation coverage?
If a notice is not disp layed at the work place , then ask your em ployer; if you are n ot satisfied w ith
your employer's answer, contact the Arkansas W orkers' Com pensation Com mission.
What is covered?
W orkers' compensation covers accidental injuries which arise out of, and in the course of
em ployment, caus e internal or external harm to the bod y, are caused by a spec ific incident and are
identifiable by tim e and place of o cc urrence. T here are three exceptio ns to th e specific incident, an d tim e
and place requirement: (1) rapid repetitive motion injuries, including carpal tunnel; (2) gradual on-set back
injuries; and (3) hearing loss. These three injuries are compensable only in those cases in which the
resultan t co ndition is the "m ajo r cause" of the need for treatm ent and/o r dis ability or death . Majo r cause is
defined as more than 50% of the cause.
Men tal injuries and heart attacks are address ed by specific statutory provisions. A m ental injury
must be caused by a physical injury to the employee's body, and disability benefits are limited to 26
weeks. However, the physical injury requirement shall not apply to any victim of a crime of violence.
A heart attack is compensable only if an accident is the major cause of the physical injury. The
exertion of work which caused the heart attack m ust have been extraordinary and unusual in comparison
to the employee's regular employment. Or, some unusual and unpredicted incident must have occurred
which was the m ajor cause o f the physical harm.
The law also provides coverage for occupational diseases which arise out of and are in the course
of employment. Ordinary diseases of life to which the general public is exposed are not covered as a
general rule.
Wh en is coverage effective?
Covera ge begins the first m inute on the job and con tinues during em ployment. You do n ot have
to work a certain length of time, and there is no need to earn a certain amount in wages before being
protected.
How do I get the benefits?
You should report the injury to the your employer or supervisor imm ediately. You should give the
em ployer w ritten no tice of the tim e, plac e an d na ture o f the inju ry and suc h ad ditional inform ation to
enable the employer to arrange medical treatment and to complete all necessary reports. Prompt
reporting is the key. Benefits are automatic, but nothing can happen until the employer knows about the
injury. Pro tect you r rights to benefits by giving the em ployer n otice o f the inju ry, no m atter how s light.
Even a cut finger can be disabling if an infection develops.
How is medical care provided?
The em ployer or insurer sho uld provide you with a copy of your rights to med ical care (W CC Form
AR-N). The law obligates the employer to provide all reasonably necessary medical care. It also entitles
the employer who has contracted with a certified managed care organization or has obtained internal
managed care certification to designate the initial provider of that care. The employer and insurer may not
be required to pay for treatment you seek on your own without their knowledge. However, the employer
and insurer may authorize you to see your own doctor. You should check with the employer or the
insurance company about any medical treatment you need. Problems concerning treatment can be
solved by cooperation between the worker and the employer or insurer in most cases.
If the claim for benefits is denied, the employer or insurance carrier may still be responsible for
treatment of services if: (1) you request medical assistance in writing prior to seeking medical attention;
(2) the employer refuses to refer you to a medical provider within 48 hours after the written request; (3) the
alleged injury is found to be compensable; and (4) the employer has not made a previous offer of medical
treatm ent.
What if I need emergency treatment immediately and am unable to seek the medical treatment
provide d by the em ploye r and insurer?
In an emergency requiring immediate treatment, you may seek emergency treatment and the
em ployer o r insurer m ay be requ ired to p ay for s uch treatm ent.
How can I change physicians?
The Arkansas W orkers' Com pensation Law sets forth specific procedures which must be followed
to determine if a change of physician is appropriate. If the employer or insurance carrier has not approved
your change of physician request, you may contact the Legal Advisor Division of the W orkers'
Com pensation Com mission regarding the change of physician procedure. Failure to follow the change of
physician rules could result in denial of payment for medical treatment from that physician. Change of
Physician requests cannot be approved over the telephone by the Legal Advisor Division.
If unable to work as a result of an accidental injury on the job, how long must I be off before I am
entitled to disability benefits?
Disability benefits are not paid for the first seven days of disability, comm encing the day after the
injury, if the disability does not last fourteen (14) calendar days. If the disability does last fourteen (14)
calendar da ys, b enefits are payable beginning the day follo wing the injury.
Wh at are the benefits?
The law provides three kinds of workers' compensation benefits:
(1) Medical care to treat the injury - not just doctor bills, but also medication, hospital costs, fees
for lab tests, x-rays, crutches an d so forth. There is no de ductible and all costs for reasonably necess ary
services are paid directly to the provider by the employer's insurance company or the self-insured
em ployer;
(2) Rehabilitation services. Sometimes this is just an extension of medical treatment, for
exam ple, physical therapy to strengthe n m uscles. H ow ever, if the injury res ults in perm anent disability,
you may qualify for vocational rehabilitation; and
(3) Cash p ayme nts. More often than no t, cash paym ents m ade to injured worke rs are in the form
of temporary total disability benefits. These payments are made during the healing period while the
employee suffers a total incapacity to earn wages. If the injury results in a permanent impairment, such as
the am puta tion of a finger or loss of us e of the sh oulder, you will be pa id perm ane nt partial disab ility
benefits after being released to return to work. If your impairment has affected your pre-injury wages, you
may be entitled to wage loss. If the injury resulted in death, payments may be made to surviving
dependents.
How much are the cash payments?
The benefits provided for temporary total disability are calculated at sixty-six and two-thirds
percent (66-2/3%) of the injured worker's average weekly wage - not to exceed a maximum rate as set by
state law. W orkers' compensation payments are tax-free. Should you have any questions about your
benefit rate, you can contact the adjuster at the insurance company or a Legal Advisor at the Arkansas
W orke rs' Com pensatio n C om m ission.
How often should compensation for lost time be paid?
Every other week , norm ally.
Wh en are the cash payments mad e?
If you report the injury promptly, you should receive the first compensation check within fourteen
(14) days, not including the date of injury. After that, you should receive a check every two weeks until you
are no longer disabled. In extremely serious injuries, the payments may continue for life.
Do I need to apply for benefits with the Workers' Compensation Commission?
No. Employers or insurers should provide medical treatment, appropriate disability payments and
file the required reports and notices with the Workers' Compensation Comm ission. If they do not, you
should call the W orkers' Com pensation Com mission regarding your legal rights.
W h at if th ere is a p ro ble m ?
Most claims are handled routinely. After all, workers' compensation benefits are automatic and
the amounts are set by the Legislature. But mistakes and misunderstandings do happen. If you think you
have not received all benefits due, you can contact the employer or the insurance company. Many
questions can be cleared up with a phone call. If still not satisfied with the explanation, they may get
advice from the W orke rs' Com pensatio n C om m ission office (ph one num bers listed in the back of this
brochure). The Comm ission staff includes trained persons who are ready, willing, and qualified to advise
you about your rights and benefits under our law. Th ese pers ons can also arrange prelim inary
conferences where you can meet with the employer or the employer's representative to discuss any
problems in getting benefits. Many problems and disputes can be resolved by Legal Advisors through the
Preliminary Conferen ce p rocedu re or m ediation, sa ving the pa rties litigation cos ts.
If the problem still cannot be resolved, it may be necessary to file a "Form C" with the Workers'
Com pensation Com mission. This state agency reviews cases when you believe you have been denied
benefits unjustly. The claim should be filed on W CC Form AR-C. Claim for Com pensation, which may be
obtained at any W orkers' Com pensation Com mission office or by contacting the Arkansas W orkers'
Com pensation Com mission, P.O. Box 950, Little Rock, Arkansas 72203-0950.
When must the claim be filed?
The law requires that your claim be filed within two (2) years from the date of injury or death, or
one year from the date of last payment of compensation.
W h at h ap pe ns afte r I file a c la im ?
If the dispute cannot be resolved at a preliminary conference or mediation, the case will be
assigned upon request, to an Administrative Law Judge of the Comm ission, who will conduct further
proceedings in the matter. Either party may hire an attorney to represent them at the hearing.
W h at w ill the a tto rn ey's fe es be fo r h andling a workers' com pensation claim ?
Under the W orkers' Com pensation Law, fees for legal services are not valid unless approved by
the Comm ission. In contested cases, one-half (1/2) of the attorney's fee is paid by the employer or the
insurance carrier and one-half (1/2) by you out of compensation awarded. This means that under normal
circumstances, unless you are awarded benefits, you do not owe an attorney's fee.
Wh at compensation is provided if I receive an anatomical impairment rating from m y physician as
a result of the a cciden t or injury?
You are e ntitled to re ceive perm ane nt partial disab ility ben efits fo r a pre scribed num ber o f weeks.
The Arkansas Legislature has assigned values in terms of weeks of compensation to various
parts of the bod y and to the entire bo dy.
Th e value as signed b y the Le gislature is m ultiplied by the impairm ent assigned by the physician to
determine the number of weeks of benefits to which you are entitled.
What if I am not satisfied with the amount of disability reported by the physician?
You do not have to accept an impairment rating from a physician or a settlement proposed by the
em ployer o r its representa tives. Yo u m ay, as w ith any dispute which arises in th e ca se, re que st a
preliminary conference or mediation with a Legal Advisor of the W orkers' Com pensation Com mission
regarding your legal options.
W hile temp orarily unable to w ork as a resu lt of the injury, for how long ca n I receive disa bility
payments?
The workers' com pensatio n Law pro vides for tem porary total disability benefits w hile you are in
your healing period and unable to earn wages.
Must the employer keep the job open until I return?
Although the W orkers' Com pensation Law provides that an employer cannot discharge or
discriminate against you for exercising your rights under the W orkers' Com pensation Law, there is no
specific requirement that an employer keep a job open while you are off work. However, any employer
who, without reasonable cause, refuses to return you to work m ay be responsible for paying the difference
in your average week ly wage and any benefits received for a period not to exce ed one (1) year.
What if I am permanently and totally disabled as a result of an accidental injury on the job?
If permanently and totally disabled, then you are entitled to benefits for life.
W hat if I w ant to settle m y case with the em ploye r and insurer?
All final settlements m ust be approved by the Arkansas W orkers' Com pensation Com mission,
and the case can only be settled if so approved.
Am I entitled to an y reimbu rsem ent for travel exp enses for me dical treatme nt?
In the normal case, you are allowed mileage for medical travel. If a dispute arises as to what
expenses shall be provided, the W orkers' Com pensation Com mission may determine the expenses to be
paid.
Wh at if I have an accidental injury on the job with an employer who is required to have workers'
compen sation coverage, but has not been approved as a self-insurer or obtained a workers'
com pens ation insu rance p olicy?
You m ay still file a claim with the Co m m ission under the W orke rs' Com pensatio n Law or file a civil
lawsuit aga inst the em ployer in C ircuit Court.
What is required for vocational rehabilitation?
The injury must result in a permanent impairment, and the rehabilitation plan proposed must be
reasonable in rela tion to th e disability.
How does the payment for physical and/or vocational rehabilitation affect other compensation?
The payment of the additional benefits for physical or vocational rehabilitation is in addition to any
other compensation which you may be entitled to.
W hat hap pens to any em ployee o r emp loyer wh o m isrepresen ts a w ork-related injury?
Anyone who makes false statements for obtaining or defeating the payment of benefits can be
found guilty of a Class D Felony and su bject to a fine of up to ten thousand dollars ($10,000.00).
I have a question about workers' compensation not answered in this pamphlet. What should I do?
Contact the Arkansas Workers' Compensation Comm ission and ask to speak with a Legal
Advisor.
Wh ere are the Workers' Com pensation Comm ission Offices?
Main Office Location:
324 Spring Street
Little Rock, AR 72201
501-682-3930
Legal Advisor Division
501-682-2707
Mailing Address:
P.O. Box 950
Little Rock, AR 72203-0950
The following are branch offices:
Fort Smith Division
616 Garrison
Fort Smith, AR 72901
479-783-7970
Springdale Division
244 Sou th 40th
Springdale, AR 72762-3845
479-751-2790
You m ay call the
1-800-622-4472
1-800-250-2511
1-800-852-5376
1-80 0-35 4-27 11
1-800-285-1131
Co m m ission at no cos t by using ou r toll-free num bers listed be low:
- Little Rock
- Legal Advisor Division, L. R.
- Sp ringdale
- F ort Sm ith
- Deaf Access
NOTICE
This pam phlet is not intended to be a detailed or definitive statement of the law. If you have
specific questions about your rights or obligations under the Arkansas W orkers' Com pensation Act, you
m ay wish to em ploy a priva te attorney.
This Comm ission does not discriminate on the basis of race, color, national origin, sex, religion, age or
disability in employment or the provision of services.
REVISED 01-10
To the Injured Worker:
On your first visit, please give this notice to any
pharmacy listed on the back side to speed processing
your approved workers’ compensation prescriptions
(based on the guidelines established by your
employer).
Questions or need assistance locating a participating
retail network pharmacy? Call the Express Scripts
Patient Care Contact Center at 1-866-590-5882.
GJC6200
Atencion Trabajador Lesionado:
Este formulario de identificación para servicios
temporales de prescripción de recetas por
compensación del trabajador DEBERÁ SER
PRESENTADO a su farmacéutico al surtir su(s)
receta(s) inicial(es).
Si tiene cualquier duda o necesita localizar una
farmacia participante, por favor contacte al área de
Atención a Clientes de Express Scripts, en el teléfono
1-866-590-5882.
To the Pharmacist:
Express Scripts administers this workers’
compensation prescription program. Please follow the
steps below to submit a claim. Standard claim
limitations include quantity exceeding 150 pills or a
day supply exceeding 14 days. This form is valid for
up to 30 days from DOI. Limitations may vary. For
assistance, call Express Scripts at 1-866-590-5882.
Pharmacy Processing Steps
Step 1: Enter bin number 003858
Step 2: Enter processor control A4
Step 3: Enter the group number as it appears above
Step 4: Enter the injured worker’s nine-digit ID number
Step 5: Enter the injured worker’s first and last name
Step 6: Enter the injured worker’s date of injury
Thank you for using a participating retail network
pharmacy. Even though there is no direct cost to you,
it’s important that we all do our part to help control the
rising cost of healthcare.
Please see other side for a list of participating retail
network pharmacies.
To the Supervisor: Please fill in the
information requested for the injured worker.
A&P
Acme Pharmacy
Albertson’s
Albertson’s/Acme
Albertson’s/Osco
Albertson’s/Sav-On
Amerisource
Bergen
Anchor Pharmacies
Arrow
Aurora
Bartell Drugs
Bigg’s
Bi-Lo
Bi-Mart
BJ’s Wholesale
Club
Brooks
Brookshire Brothers
Brookshire Grocery
Bruno
Carrs
Cash Wise
Coborn’s
Costco
Cub
CVS
D&W
Dahl’s
Dierbergs
Discount Drugmart
Doc’s Drugs
Dominicks
Drug Emporium
Drug Fair
Drug Town
Drug World
Eckerd
Econofoods
EPIC Pharmacy
Network
FamilyMeds
Farm Fresh
Farmer Jack
Food City
Food Lion
Fred’s
Gemmel
Giant
Giant Eagle
Giant Foods
Hannaford
Harris Teeter
H-E-B
Hi-School
Pharmacy
Hy-Vee
Jewel/Osco
Kash n Karry
Keltsch
Kerr
Kmart
Knight Drugs
Kroger
LeaderNet (PSAO)
Longs Drug Store
Major Value
Marsh Drugs
Medic Discount
Medicap
Medistat
Meijer
Minyard
NCS HealthCare
Neighborcare
Network
Pharmaceuticals
Northeast
Pharmacy Services
Osco
P & C Food
Markets
Pamida
Park Nicollet
Pathmark
Pavilions
Price Chopper
Publix
Quality Markets
Raley’s
Randalls
Rite Aid
Rosauers
Rx Express
RXD
Safeway
Sam’s Club
Sav-On
Save Mart
Schnucks
Scolari’s
Sedano
Shaw’s
Shop ‘N Save
Shopko
ShopRite
Snyder
Stop & Shop
Sun Mart
Super Fresh
Super Rx
Target
Texas Oncology
Srvs
The Pharm
Thrifty White
Times
Tom Thumb
Tops
Ukrop’s
United Drugs
United
Supermarkets
Vons
Waldbaums
Walgreens
Wal-Mart
Wegmans
Weis
Winn Dixie