Connecticut - AIM Mutual Insurance Companies

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A.I.M. Mutual Insurance Company
Associated Employers Insurance Company
Massachusetts Employers Insurance Company
New Hampshire Employers Insurance Company
Claim Kit
in
partnership
with
you
On behalf of the A.I.M. Mutual Insurance Companies, I welcome you as a policyholder.
As your new workers compensation insurance carrier, we ask that you report all accidents
to us as soon as possible after they occur. Your prompt notification together with a
complete accident report will help us to handle your claims fairly and efficiently.
Enclosed is a supply of the necessary forms along with instructions for their use. Please
feel free to contact us at any time with your questions or service requests.
Sincerely,
Laura Parsons, WCLA, FCLA
Director of Claims
Connecticut Claim Team
Director of Claim
Office:
800-876-2765 X 8890
Fax:
781-270-5599
Laurie Parsons, WCLA, FCLA
Claim Supervisor
Offce:
800-876-2765 X 8746
Fax:
781-270-5599
Catherine McKeever
Sr. Claim Representative
Office:
800-876-2765 X 8850
Fax:
781-270-5599
Keith Mailloux
Claim Representative
Office:
800-876-2765 X 8730
Fax:
781-270-5599
Christopher Moncada
Sr. Regional Claim Specialist
Office:
413-535-5060
Cell:
508-667-0276
Fax:
413-535-5001
Dottie Tatoian
What to do when an employee has a work-related injury:
Assess the extent of the injury. Provide first aid if appropriate.
If the employee requires medical attention, accompany him/her to an
approved primary care facility.
In case of a catastrophic injury, immediately call 911.
Secure the accident scene.
Complete the Employers First Report of Injury or Occupational Illness
(FRI).
Fax the FRI to 781-270-5599, report on-line at www.aimmutual.com,
or call into the reporting service.
If the employee will be disabled beyond the date of injury, complete
Form 1A-Filing Status and Exemption.
If the employee is able, have him/her sign the Authorization for
Release of Medical Records.
NOTE: If at any time you receive a Form 30 C submitted by one of your
employees, it is imperative that you immediately fax it to A.I.M. Mutual
and also contact the adjuster assigned to your account.
CT 100213
54 Third Avenue, Burlington, MA 01803-0970
Workers Compensation Claim Reporting Options - Connecticut
In the event of a serious accident, call us immediately at 1-866-270-3354
(toll free 24-hour/7 day a week claim reporting)
Choose from several different ways to report your workers compensation claims to us:
By Fax:
For Medical Only claims, complete and fax the First Report of Injury (FRI) form into us at 1-781-270-5599.
OR
This form must be submitted for injuries that result in incapacity for one day or more. We will notify the state of
Connecticut Workers’ Compensation Commission in the event a Medical Only claim changes to a lost time.
On-Line, over the Internet (preferred method):
Sign on to www.aimmutual.com and click “Report A Claim”.
Select To Report A Claim Online and then click on Connecticut. You will be prompted to answer a series of
questions similar to the information necessary to complete a First Report of Injury. After answering all of the
questions and clicking on SEND, you will receive a message stating your claim has been submitted. It will also
state that a Claim Acknowledgement letter containing the claim number and assigned claim representative will
be mailed to your company after registration has been completed. Click Print for a copy of the information you
sent. We will complete and submit the First Report of Injury (FRI) to the state of Connecticut Workers’
Compensation Commission. This form must be submitted for injuries that result in incapacity for one day or
more. We will notify the state of Connecticut Workers’ Compensation Commission in the event a Medical Only
claim changes to a lost time.
By Phone:
Report claims by calling toll free: 1-866-270-3354.
This line is established for reporting new claims only, and facilitates the initial claim reporting process.
You will receive a completed First Report of Injury (FRI) and a confirmation letter, followed by a claim
acknowledgment letter including the name of the Claim Representative assigned to your case. We will submit
the FRI to the state of Connecticut Workers’ Compensation Commission. We will also notify the state of
Connecticut Workers’ Compensation Commission when a Medical Only claim has been changed to a lost time
claim.
After the initial claim report: Please direct ongoing claim and service inquiries to your Claim
Representative at our toll free telephone number:
1-800-876-2765
By Mail:
To facilitate your claim handling, please consider submitting your first report online or by fax or phone.
If you need to mail related materials to us, direct it to:
A.I.M. Mutual Insurance Companies, 54 Third Avenue, P.O. Box 4070, Burlington, MA 01803-0970
STATE OF CONNECTICUT
WORKERS’ COMPENSATION COMMISSION
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
BY A HOSPITAL/PROVIDER
FOR THE PURPOSE OF ADMINISTERING A
CONNECTICUT WORKERS’ COMPENSATION CLAIM FOR BENEFITS
PATIENT NAME: ______________________________________ DATE OF BIRTH: ___________________
(PLEASE PRINT NAME)
(REQUIRED)
BODY PART(S): ____________________________________________________________________________
I, the undersigned, authorize: __________________________________________________________________
(HOSPITAL/PROVIDER)
to disclose, in writing, protected health information [PHI] to:
____________________________________________________________________________________________
(PERSON OR ENTITY TO WHOM INFORMATION IS TO BE DISCLOSED)
and its attorneys and/or representatives. The PHI to be disclosed is relevant medical records and reports relating to
my medical treatment/consultation/examination and/or diagnostic procedures performed at the above-named
medical facility and which pertain to an injury/occupational disease for which I am claiming benefits under the
Connecticut Workers’ Compensation Act. I understand the information disclosed based on this authorization may
include mental health treatment records and information regarding HIV/AIDS status, treatment or testing.
INFORMATION RELATING TO TREATMENT FOR ALCOHOL AND DRUG ABUSE WILL NOT BE
RELEASED WITHOUT MY SPECIFIC CONSENT in accordance with state and federal law. 1 I understand
I have the right to inspect or copy the PHI to be disclosed as permitted under federal HIPAA law and state law.
I UNDERSTAND THAT I HAVE THE RIGHT TO REFUSE TO SIGN THIS AUTHORIZATION.
I UNDERSTAND THAT I HAVE THE RIGHT TO REVOKE THIS AUTHORIZATION. In order to revoke
this authorization I may, at any time, send written notification to the above-named HOSPITAL/PROVIDER.
I understand that my revocation of this authorization is ineffective to the extent that the above-named
HOSPITAL/PROVIDER has relied on this authorization to disclose PHI relating to me.
I UNDERSTAND THAT PHI DISCLOSED PURSUANT TO THIS AUTHORIZATION MAY BE
REDISCLOSED BY THE PERSON OR ENTITY I HAVE IDENTIFIED ABOVE AND MAY NO
LONGER BE PROTECTED FROM DISCLOSURE TO OTHERS BY FEDERAL OR STATE LAW.
I understand that the above-named HOSPITAL/PROVIDER may not condition my treatment on whether I provide
authorization for the requested use or disclosure.
I UNDERSTAND THAT I HAVE THE RIGHT TO DETERMINE A DATE OR EVENT AT WHICH TIME
THIS AUTHORIZATION EXPIRES. I am identifying the expiration date of this authorization to be
COMPLETION OF WORKERS’ COMPENSATION LITIGATION AS EVIDENCED BY A STIPULATION OR
FINDING AND AWARD/DISMISSAL, OR IN THE EVENT OF APPELLATE REVIEW, A FINAL
DETERMINATION BY THE HIGHEST APPELLATE AUTHORITY TO WHOM AN APPEAL IS MADE.
I further understand that federal HIPAA law does not require me to provide an authorization in this form as the
purpose of this authorization relates to a Workers’ Compensation matter. However, I understand that as a practical
matter, my authorization in this form may facilitate the processing and administration of my claim for Workers’
Compensation benefits.
My signature below indicates that I have read and understand this Authorization and its terms.
_________________________________________
________________________________________
Signature of Patient
Date
1
Any consent to release information pertaining to treatment for drug and alcohol abuse must conform to the requirements of state law and the
federal regulations, e.g., Part 2 of Title 42 of the Code of Federal Regulations.
Effective June 1, 2004/Revised November 23, 2009
Send this form to: Workers’ Compensation Commission, 21 Oak Street, Hartford, CT 06106-8011
FRI
Rev. 7-13-2009
State of Connecticut
Workers’ Compensation Commission
Date filed in Chairman’s Office
Employer’s First Report of Occupational Injury or Illness
File pursuant to C.G.S. § 31-316 for injuries that result in INCAPACITY FOR ONE DAY OR MORE. Please TYPE or PRINT IN INK.
Employer (Name, Address & Zip)
Jurisdiction
SIC Code
(for WCC use only)
Carrier / Administrator Claim #
Phone #
OSHA Log Case #
Report Purpose Code
Jurisdiction Claim #
Employer’s Location Address (if different)
Phone #
Claims Administrator (Name, Address & Zip)
Phone #
FEIN
Carrier (Name, Address & Zip)
Phone #
Policy / Self-Insured #
q
Employee: Last Name
First Name
D.O.B. (required)
Middle Name
Phone #
Address (incl. Zip)
Check, if Self-Insured
Gender
q Male
Policy Period (MM/DD/YY)
FROM:
TO:
Date Hired (MM/DD/YY)
State of Hire
Occupation / Job Title
NCCI Class Code
q Female
Rate of Pay $ ______________________ . ________ per
q Hour q Day q Week q Bi-Weekly q Other
Date of Injury / Illness (MM/DD/YY)
Town of Injury / Illness
Time Employee Began Work
Time of Occurrence
q
q
q
a.m. Did Injury / Illness occur
on Employer’s Premises?
p.m.
cannot be determined
q
q
Physician / Health Care Provider (Name, Address & Zip)
q Yes q No
Type of Injury / Illness
a.m.
p.m. Part of Body Affected
Date Employer Notified (MM/DD/YY)
Hospital (Name, Address & Zip)
Type of Injury / Illness Code
Date Disability Began (MM/DD/YY)
Part of Body Affected Code
Date Last Worked (MM/DD/YY)
Date Return(ed) to Work (MM/DD/YY)
Were Safeguards or Safety
Equipment provided?
If provided, were they used?
If Fatal, Date of Death (MM/DD/YY)
q Yes q No
q Yes q No
How Injury / Illness Occurred — Describe the sequence
of events, including any objects or substances that
directly injured the employee or made the employee ill:
All equipment, materials, and/or chemicals employee
was using when accident or illness exposure occurred:
Initial Treatment
q No Medical Treatment
q Emergency Care
q Minor — by Employer
q Hospitalized More Than 24 Hours
q Minor — by Clinic / Hospital
q Future Major Medical — Lost Time
Date Administrator Notified (MM/DD/YY)
Specific activity and/or work process employee was
engaged in when accident or illness exposure occurred:
Preparer’s Name & Title
Contact Name
Phone #
Cause of Injury Code
Anticipated
Date Prepared (MM/DD/YY)
Phone #
Please TYPE or PRINT IN INK
1A
Rev. 7-13-2009
State of Connecticut
Workers’ Compensation Commission
WCC File #
Filing Status and Exemption
Date filed in District
This form must be executed in every case of compensable disability for injuries occurring
ON OR AFTER October 1, 1991, and must be completed in its entirety.
EMPLOYEE
Name
Date of Birth (required)
Address
City/Town
State
Zip Code
(for WCC use only)
FILING STATUS AND EXEMPTIONS — In order to determine your weekly benefit rate, as per
Sec. 31-310 C.G.S.,we need the following information:
DATE OF INJURY:
1. Select your Federal tax filing status based upon your ACTUAL filing status as of the date of injury, listed at right:
(Must match your tax return, as if you were filing with the IRS on the date of your injury.)
q Single
q Head of Household
q Married filing jointly
q Married filing separately
2. Number of exemptions (including yourself) as of the date of injury listed at right =
3. FICA withheld for the above-named employee? .............................. q YES .................
q NO — If NO, insurer must manually calculate weekly benefit rate.
4. Check all appropriate boxes:
q Employee 65 years of age or older
q Employee legally blind
q Spouse 65 years of age or older
q Spouse legally blind
5. List name (yourself first), date of birth, and relationship to you for all exemptions included in question #2, above:
Name
Date of Birth
Relationship
SELF
CONCURRENT EMPLOYMENT — To be certain you receive all the benefits to which you are entitled, provide the following information
if you were working for more than one employer on the date of injury indicated above:
Name of Employer
Address
Date of Hire
NOTE: Wage information for each concurrent employer must be supplied by the claimant.
SIGNATURE OF INJURED WORKER OR REPRESENTATIVE
I hereby attest that the above information is correct to the best of my knowledge.
Employee’s Signature
Date
Rev. 9-26-2011
Workers’ Compensation — Employee Medical & Work Status Form
Give a copy to employee at time of visit n File a copy in medical file
Fax a copy to carrier, TPA, employer, or designee within one business day of visit
To Be Completed by Attending Physician/Office
Employee Name:
Date of Birth:
(last)
(first)
/
/
(middle)
Employer Name:
Department/Division:
Employer Address/Location:
Initial or Follow-Up Visit
(circle one)
Date of Injury/Illness:
Payer/Managed Care Plan Name:
/
/
Claim#:
Date of this visit:
/
q
/
(as stated by employee):
Employee’s job
Employee will be seen in this office for
follow-up on
/
/
.
WORK STATUS - Having evaluated/treated this employee today, in my opinion:
q
Employee may continue regular work duty.
q
Employee may return to his/her regular work on
q
Employee can return to work on
/
/
without restriction.
with the following functional capabilities: In an 8-hour workday, employee may:
2-4 hours
4-6 hours
6-8 hours
None
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
q
Walk
Sit
Bend/Squat
Climb
Reach
Twist
Crawl
Drive
Foot/Feet
Hand(s)
Patient is able to lift
/
/
There is no change from prior visit.
1-2 hours
Stand
q
q
q
Patient is unable to lift greater than
pounds.
Patient may use
q
RIGHT
q
LEFT
q
BOTH foot/feet for repetitive movement as in operating foot controls.
Patient may use
q
RIGHT
q
LEFT
q
BOTH hands for repetitive
The restrictions noted above are in effect until
/
/
q
single grasping
fine manipulation
q
pushing and pulling.
.
q
Employee is Temporarily Totally Disabled until
q
Employee is on medication that will restrict his/her ability to work safely. Explain:
/
q
/
or pending recheck here on
/
/
.
I HAVE DISCUSSED THIS PATIENT’S WORK RESTRICTIONS TELEPHONICALLY TODAY WITH HIS/HER EMPLOYER’S REPRESENTATIVE, OR HAVE
COMPLETED THE EMPLOYER’S WORK STATUS FORM IN LIEU OF COMPLETING THE RESTRICTION PORTION OF THIS FORM. RELEASE TO REGULAR
DUTY WITHOUT RESTRICTIONS AND/OR TOTAL DISABILITY MUST BE DOCUMENTED USING THIS FORM OR THE EMPLOYER’S STANDARD FORM.
DIAGNOSIS:
Provider Name
TREATMENT PLAN:
(print):
Provider Address:
Provider Signature:
Date:
/
/
I have received a copy of this document—Employee Signature:
Date:
/
/
Please TYPE or PRINT IN INK
30C
Rev. 8-23-2010
State of Connecticut
Workers’ Compensation Commission
WCC File #
Notice of Claim for Compensation
Date filed in District
(Employee to Commissioner and to Employer)
This form prepared by the WCC is proper for ordinary use and is recommended,
but any other notice complying with Section 31-294c shall be deemed sufficient.
Notice is hereby given that the injured worker, while in the employ of the employer, sustained
injuries arising out of and in the course of his/her employment as follows, and makes
claim for compensation benefits.
(for WCC use only)
INJURED WORKER
INJURY
Name
Date of Injury
(first)
(middle)
(last)
Town of Injury
D.O.B. (required)
Body Part(s)
Describe Injury and How It Happened:
Check, if a Minor

(under 18 yrs. of age)
Address
Town
State
Zip Code


Tel.#
EMPLOYER
Check, if an Occupational Disease or a Repetitive Trauma
Check, if you have MORE THAN ONE Employer
SIGNATURE OF INJURED WORKER OR REPRESENTATIVE
Employer
Signature
Address
Date
Town
State
Zip Code
Print name & address below, if other than injured worker:
Tel.#

Was Injury ON Premises of Employer?
YES

NO
Name
If NO, where?
Name of Firm
Address
Address
Town
Town
Zip Code
Tel.#
Zip Code
State
Tel.#
This notice must be served upon the Commissioner and *Employer by personal presentation or by registered or certified mail. For the protection of both
parties, the employer should note the date when this notice was received and the claimant should keep a copy of this notice with the date it was served.
* Persons employed by the State of Connecticut must also serve the employer by serving this notice upon the Commissioner of Administrative Services,
165 Capitol Avenue, Hartford, CT 06106.
WARNING:
If an employer does not file a notice contesting liability (e.g. Form 43) for this claim OR begin making workers’ compensation benefit
payments “without prejudice” within 28 calendar days from the date when this claim is received by personal delivery or by registered or
certified mail, COMPENSABILITY SHALL BE PRESUMED and cannot thereafter be contested. If an employer chooses to begin making
workers’ compensation benefit payments “without prejudice” within 28 calendar days from the date of receipt of this claim and still
wishes to contest this claim, it must do so by filing a notice contesting liability for this claim within one year from receipt of this claim.
[See Sec. 31-294c(b).]
7
5
4
3
8
2
[effective 5-1-06]
State of Connecticut
Workers’ Compensation Districts
6
1
A 30C Form should be filed promptly after a work-related injury or illness takes place. There is a statute of limitation for filing workers’ compensation
claims: within one year of the date of an accidental injury or within three years from the first manifestation of a symptom of an occupational disease.
[NOTE: If, within the applicable time period described above, (1) there has been a hearing or a written request for a hearing or an assignment for a
hearing or (2) your employer’s insurance carrier has already signed a Voluntary Agreement, you do NOT need to file a 30C Form for the injury or illness
it covers.]
You Should File A 30C Form Because . . .
·
·
·
·
·
There will be no doubt that you are claiming that you have a work-related injury or occupational disease.
It is the best way to insure that you have met the statute of limitations for filing a workers’ compensation claim.
A simple “accident report” filed with the employer is not an official claim for workers’ compensation.
Your claim will be more likely to receive prompt attention from your employer or insurance carrier.
Once your employer receives an official claim, they have only 28 calendar days in which to either deny your claim or to begin making workers’
compensation benefit payments “without prejudice.” If an official denial is not issued within 28 calendar days or if benefit payments are not initiated
within 28 calendar days, your employer must accept the compensability of your claim.
Directions for Completing the 30C Claim Form
Please pay close attention to these directions.
When filling out a 30C Form, remember to Type or Print Neatly In Ink (except for signatures).
In filling out the 30C Form, please note the following:
1. In the “INJURED WORKER” box at the upper left side of the form, type or neatly print the name of the injured worker
(If YOU are the injured worker, print YOUR name here.). Also fill in the injured worker’s D.O.B. (date of birth), put a check
in the box, if the worker is a minor (under the age of 18) and fill in the injured worker’s street address, town, state, zip code,
and telephone number.
2. In the “EMPLOYER” box at the lower left side of the form, type or neatly print the name of the employer (“Name of employer”
means the name of the organization for which you work, NOT your boss or supervisor.) and its street address, town, state, zip code,
and telephone number. Next indicate (YES or NO) whether the injured worker’s injury occurred at the employer’s location just
listed; if the injury took place at a location other than that listed, fill in the location, street address, town, state, zip code, and
telephone number where the injury actually occurred.
3. In the “INJURY” box at the upper right side of the form, type or neatly print the date of the injured worker’s injury and the
town in which the injury occurred (Note the city or town in which the injury actually occurred. This will not necessarily be the same
location as the employer’s business address!). Next indicate the part(s) of the worker’s body injured and how the injury occurred
(In the blank space describe your injury in simple terms. Indicate the part(s) of your body affected and the type(s) of injury. For
example: “sprain to the right shoulder”, “amputation of the left thumb”, “fracture of the right ankle”, “severe strain to lower back”,
etc.). Lastly, indicate (YES or NO) whether the injury is an occupational disease or a repetitive trauma, and check the
appropriate box, if you have more than one employer.
4. In the “SIGNATURE OF INJURED WORKER OR REPRESENTATIVE” box at the lower right side of the form, sign your name and fill in
the date of your signature, if you are the injured worker. If you are NOT the injured worker, then sign your name, fill in the date
of your signature, and then type or neatly print your name, the name (if any) of your firm, your street address, town, state, zip
code, and your telephone number.
5. In the “WCC File #” box at the upper right side of the form (just below the “30C” number with the black background), type or neatly
print the WCC File Number, ONLY IF YOU KNOW IT. In most instances, this number will be assigned to your claim by the
Workers’ Compensation Commission only after you send the 30C Form in, so it is okay to leave this one area of the form blank, if
you are not absolutely sure of the number.
Once you have completed the 30C Form, follow these procedures:
6. Make two (2) extra copies of your completed 30C Form (this can be done at many quick-copy printers).
7. Send the original 30C to your employer by Certified or Registered mail, return receipt requested. The claim may also be delivered in
person but if so, have the employer acknowledge in writing the receipt of the claim. State employees’ work-related injuries and illnesses
are reported on Form PER-WC 207, entitled “Report of Occupational Injury or Disease to an Employee”. If a State employee elects to
file a 30C Form, then he or she must send the 30C Form to the Commissioner of Administrative Services, 165 Capitol Avenue,
Hartford, CT 06106, NOT to the particular office where employed. (The Form PER-WC 207 is ONLY an accident report and is NOT
the official claim form for workers’ compensation benefits — State employees, like any other employees, must file a 30C Form in order
to file an official workers’ compensation claim.)
8. Send a copy of the 30C to the appropriate Workers’ Compensation Commission District Office by Certified or Registered mail,
return receipt requested, or deliver by personal presentation. Addresses for all Workers’ Compensation Commission District Offices
may be found in this packet of material. The “District Office”refers to the number given to the District Workers’ Compensation
Commission Office for the town in which you were injured. Refer to the Connecticut map provided with the Form 30C for the
number of the Compensation District for the town in which you were injured.
9. Keep the remaining copy of the 30C for your own file.
Workers’ Compensation Commission District Offices
District 1 — Hartford
District 5 — Waterbury
999 Asylum Avenue
Hartford, CT 06105
55 West Main Street
Waterbury, CT 06702
Phone: (860) 566-4154
Fax: (860) 566-6137
Phone: (203) 596-4207
Fax: (203) 805-6501
District 2 — Norwich
District 6 — New Britain
55 Main Street
Norwich, CT 06360
233 Main Street
New Britain, CT 06051
Phone: (860) 823-3900
Fax: (860) 823-1725
Phone: (860) 827-7180
Fax: (860) 827-7913
District 3 — New Haven
District 7 — Stamford
700 State Street
New Haven, CT 06511-6500
111 High Ridge Road
Stamford, CT 06905
Phone: (203) 789-7512
Fax: (203) 789-7168
Phone: (203) 325-3881
Fax: (203) 967-7264
District 4 — Bridgeport
District 8 — Middletown
350 Fairfield Avenue
Bridgeport, CT 06604
90 Court Street
Middletown, CT 06457
Phone: (203) 382-5600
Fax: (203) 335-8760
Phone: (860) 344-7453
Fax: (860) 344-7487
Connecticut MCO Preferred Provider Network
for Policyholders of A.I.M. Mutual Insurance Companies
In the state of Connecticut, A.I.M. Mutual has partnered with CorVel to provide a Managed Care
Organization (MCO) for policyholders. In fact, CorVel’s MCO is one of the largest in Connecticut, with
over 5,000 participating medical providers in its preferred provider network. Through the network, injured
workers have access to 28 different medical specialties.
To apply, employers simply fill out an Employer Participation Form or CorVel will complete it on the
employer’s behalf. A CorVel representative will then be responsible for the state filing.
Frequently Asked Questions
1. What is a Medical Care Plan?
A Medical Care Plan is a managed care approach to work-related illness or injuries, approved
by the Connecticut Workers’ Compensation Commission. Under this Plan, treatment must be
obtained from a provider in the approved Preferred Provider Network in order for the injured
employee’s benefits not to be in jeopardy.
2. What is a Preferred Provider Network?
Each Managed Care Organization must file a Preferred Provider Network with the state of
Connecticut. In order to ensure ample provider coverage for injured workers, each Managed
Care Organization must abide by strict standards in order for the state of Connecticut to
approve specific specialties to be included in its Preferred Providers Network.
3. Is there an application fee?
No.
4. What is needed to implement a Medical Care Plan?
Per the Connecticut Workers’ Compensation Commission, each employer who has twenty-five
or more employees per work site, as well as each employer who has twenty-four or fewer
employees in Connecticut and whose rate of work related injury and illness exceeds the
average incidence rate, shall establish and administer a safety and health committee for that
work site. Each committee must have at least 50% labor representation and meet at least
quarterly.
5. What is the process to implement a Medical Care Plan?
CorVel submits an Employer Participation form on behalf of the employer to the State of
Connecticut’s Workers’ Compensation Commission for review and approval.
6. How long does it take to receive approval from the State?
The State of Connection has up to 6 months to review and approve an Employer Participation
form; however, most approvals are received with 30-90 days from the date of submission.
7. What happens after the State approves an Employer Participation form?
A Welcome package is sent to the employer. The package consists of a copy of the company’s
Certification of Approval, copies of CorVel’s Preferred Provider Network Directory, an
announcement of the plan to be posted in a public site easily accessible to all employees and
educational materials to be distributed to each employee.
Directory of Participating Medical Providers
For the most complete and up-to-date listing of Medical Providers, please visit the
Forms Library on our website at www.aimmutual.com and click on CorVel PPO Lookup.
The site will direct you to participating medical providers throughout Connecticut as
well as in nearby states.
CT 100213
Provider Directory
State, County Specialty
Minor
Emerg/Urgent
Care C
CT, HARTFORD Primary Care
Clinic
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, FAIRFIELD Hospital General/Acute
CT, HARTFORD
CT, FAIRFIELD
CT, FAIRFIELD
Primary Care
Clinic
Hospital General/Acute
CT, FAIRFIELD Hospital General/Acute
CT, HARTFORD Hospital General/Acute
CT, HARTFORD Primary Care
Clinic
CT, HARTFORD Occupational
Medicine Center
CT, FAIRFIELD Primary Care
Clinic
Minor
CT, FAIRFIELD
Emerg/Urgent
Care C
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
Name
Address 1
City
State
Zip
Phone
Bloomfield Urgent
Care Center
421 Cottage Grove
Rd
Bloomfield
CT
06002
(860) 242-0034
Ellis Medical Center
701 Cottage Grove
Rd Ste A110
Bloomfield
CT
06002
(860) 242-0034
Stony Creek Urgent
Care Center
6 Business Park Dr
Ste 302
Branford
CT
06405
(203) 483-4580
U S Healthworks
Medical Center
144 N MAIN ST
BRANFORD
CT
06405
(203) 481-0818
United States
Healthworks Medical
Group
144 N MAIN ST
BRANFORD
CT
06405
(203) 481-0818
Bridgeport Hospital
267 Grant St
Bridgeport
CT
06610
(203) 384-3000
4600 Main St
Bridgeport
CT
06606
(203) 371-4445
2800 Main St
Bridgeport
CT
06606
(203) 576-6000
267 Grant St
Bridgeport
CT
06610
(203) 688-2046
Bristol Hospital
41 Brewster Rd
Bristol
CT
06010
(860) 585-3000
MED Help Medical
Center
539 Farmington Ave Bristol
CT
06010
(860) 584-8900
Medworks, LLC
539 Farmington Ave Bristol
CT
06010
(860) 589-0114
P.R.O.S. Medical
Services
246 Federal Rd Ste
D12
Brookfield
CT
06804
(203) 775-3290
Urgent Care Medical
Associates LLC
31 Old Rte 7
Brookfield
CT
06804
(203) 262-1991
Midstate Medi-Quick
680 S Main St
Cheshire
CT
06410
(203) 272-3595
St. Vincent's
Immediate Health
Care
St. Vincent's Medical
Center
Yale New Haven
Hospital
CT, NEW
LONDON
Primary Care
Clinic
Conncare Inc.
163 Broadway
Colchester
CT
06415
(860) 537-4601
CT, FAIRFIELD
Primary Care
Clinic
Adult Health CenterSeifert and Ford
Family Commun
70 Main St
Danbury
CT
06810
(203) 791-5030
CT, FAIRFIELD
Occupational
Medicine Center
Hospital General/Acute
Corporate Health Care
79 Sandpit Rd Ste
302
Danbury
CT
06810
(203) 749-5720
Danbury Hospital
24 Hospital Ave
Danbury
CT
06810
(203) 739-7000
Danbury
CT
06810
(203) 791-5010
Danbury
CT
06810
(203) 797-7469
Danielson
CT
06239
(860) 779-0066
Darien
CT
06820
(203) 967-6116
East Hartford
CT
06108
(860) 289-5561
CT, FAIRFIELD
CT, FAIRFIELD
Primary Care
Clinic
CT, FAIRFIELD
Primary Care
Clinic
CT, WINDHAM
Primary Care
Clinic
CT, FAIRFIELD Hospital General/Acute
CT, HARTFORD Occupational
Medicine Center
Minor
CT, HARTFORD
Emerg/Urgent
Care C
CT, HARTFORD Occupational
Medicine Center
CT, NEW
LONDON
Primary Care
Clinic
Minor
CT, HARTFORD Emerg/Urgent
Care C, Primary
Care Clinic
CT, HARTFORD Occupational
Medicine Center
CT, HARTFORD Occupational
Medicine Center
Minor
CT, HARTFORD
Emerg/Urgent
Care C
Dental Services-Seifert
70 Main St
and Ford Family
Community
Western Ct Health
Network Medical Arts 111 Osborne St
Center
Danielson Health
55 Green Hollow Rd
Center
1500 Boston Post
Darien Medical Center
Rd
Concentra Medical
701 Main St
Centers
Concentra Urgent
Care
701 Main St
East Hartford
CT
06108
(866) 944-6046
Occupational Health
Centers of The
Southwest, PA
701 Main St
East Hartford
CT
06108
(860) 289-5561
Flanders Health
Center
339 Flanders Rd
East Lyme
CT
06333
(860) 739-6437
Enfield Ambulatory
Care Center, LLC
15 Palomba Dr
Enfield
CT
06082
(860) 745-1684
Johnson Occupational
Medicine Center
Johnson Occupational
Medicine Center
140 Hazard Ave Ste
Enfield
101
140 Hazard Ave Ste
Enfield
102
CT
06082
(860) 763-7668
CT
06082
(860) 272-2977
New England Urgent
Care
55 Hazard Ave
CT
06082
(860) 745-9911
Enfield
Minor
CT, MIDDLESEX Emerg/Urgent
Care C, Primary
Care Clinic
CT, FAIRFIELD
Primary Care
Clinic
Minor
Emerg/Urgent
Care C
CT, HARTFORD Hospital General/Acute
CT, FAIRFIELD Hospital General/Acute
Occupational
CT, FAIRFIELD Medicine Center,
Primary Care
Clinic
Occupational
CT, FAIRFIELD Medicine Center,
Primary Care
Clinic
Minor
Emerg/Urgent
CT, NEW
Care C,
LONDON
Occupational
Medicine Center,
Primary Care
Clinic
Minor
CT, NEW
Emerg/Urgent
LONDON
Care C, Primary
Care Clinic
CT, NEW
Hospital HAVEN
General/Acute
CT, HARTFORD
CT, NEW
HAVEN
CT, NEW
HAVEN
Occupational
Medicine Center
Occupational
Medicine Center
Middlesex Hospital
Shoreline Medical
Center
260 Westbrook Rd
Essex
CT
06426
(860) 358-3700
St. Vincent's
Immediate Health
Care
1055 Post Rd
Fairfield
CT
06824
(203) 259-3440
Allies Medical Group
2 Bridgewater Rd
Ste 100
Farmington
CT
06032
(860) 678-9900
John Dempsey
Hospital
263 Farmington Ave Farmington
CT
06034
(860) 679-2000
Greenwich Hospital
5 Perryridge Rd
Greenwich
CT
06830
(203) 863-3000
Greenwich Hospital
Occupational Health
5 Perryridge Rd
Greenwich
CT
06830
(203) 863-3400
Greenwich Hospital
Occupational Health
75 Holly Hill Ln
Greenwich
CT
06830
(203) 863-3400
Occupational Hlth Ctr,
52 Hazelnut Hill Rd
L&M Hospital
Groton
CT
06340
(860) 446-8265
Pequot Health Ctr,
L&M Hospital
52 Hazelnut Hill Rd
Groton
CT
06340
(860) 446-8265
Yale New Haven
Hospital
111 Goose Ln
Guilford
CT
06437
(203) 453-7900
2080 Whitney Ave
Hamden
CT
06518
(203) 789-6240
2080 Whitney Ave
Ste 150
Hamden
CT
06518
(203) 789-6240
St. Raphael's
Occupational Health
Plus
St. Raphael's
Occupational Health
Plus
CT, NEW
HAVEN
Hospital General/Acute
CT, HARTFORD Primary Care
Clinic
CT, HARTFORD Hospital General/Acute
CT, HARTFORD Hospital General/Acute
CT, HARTFORD Occupational
Medicine Center
CT, NEW
Primary Care
LONDON
Clinic
CT, NEW
LONDON
Primary Care
Clinic
CT, HARTFORD Hospital General/Acute
CT, HARTFORD Hospital General/Acute
Minor
CT, HARTFORD
Emerg/Urgent
Care C
CT, HARTFORD Hospital General/Acute
CT, TOLLAND
Primary Care
Clinic
Minor
Emerg/Urgent
Care C
CT, HARTFORD Hospital General/Acute
CT, NEW
Primary Care
HAVEN
Clinic
CT, HARTFORD
CT, NEW
HAVEN
Hospital General/Acute
CT, MIDDLESEX Hospital General/Acute
Yale New Haven
Hospital
2560 Dixwell Ave
Hamden
CT
06518
(203) 288-0003
Bariatric Surgeons of
Connecticut
1000 Asylum Ave
Hartford
CT
06105
(860) 714-4400
St. Francis Hospital
1000 Asylum Ave
Ste 3200
Hartford
CT
06105
(860) 714-4000
St. Francis Hospital
114 Woodland St
Hartford
CT
06105
(860) 714-4000
St. Francis
Occupational Health
114 Woodland St
Ste 4302
Hartford
CT
06105
(860) 714-4270
United Community &
Family Services
70 Main St
Jewett City
CT
06351
(860) 892-7042
Conncare Inc.
743 Colonel Ledyard
Ledyard
Hwy
CT
06339
(860) 464-3104
320 Main St
Manchester
CT
06040
(860) 646-1222
71 Haynes St
Manchester
CT
06040
(860) 646-1222
71 HAYNES ST
MANCHESTER
CT
06040
(860) 646-1222
320 Main St
Manchester
CT
06040
(860) 872-0501
7 A Ledgebrook Dr
Mansfield
CT
06250
(860) 456-7237
Manchester Memorial
Hospital
Manchester Memorial
Hospital
Promptcare Walk in
Urgent Care
Rockville General
Hospital
Windham Hospital
Center for Women's
Health
Marlborough Medical
Center
12 Jones Hollow Rd Marlborough
CT
06447
(860) 358-3200
Middlesex Hospital
3 E Hampton Rd Ste
Marlborough
13
CT
06447
(860) 344-6000
Comprehensive
Dialysis Care
61 Pomeroy Ave
Meriden
CT
06450
(203) 238-1962
Midstate Medical
Center
435 Lewis Ave
Meriden
CT
06451
(203) 694-8200
Middlesex Hospital
28 Crescent St
Middletown
CT
06457
(860) 344-6000
CT, NEW
HAVEN
Hospital General/Acute
Milford Hospital
300 Seaside Ave
Milford
CT
06460
(203) 876-4553
CT, FAIRFIELD
Primary Care
Clinic
St. Vincent's
Immediate Health
Care
401 Monroe Tpke
Monroe
CT
06468
(203) 268-2501
CT, WINDHAM
Primary Care
Clinic
Conncare Inc.
122 Plainfield Rd
Moosup
CT
06354
(860) 564-2198
Primary Care
Clinic
Seaport Clinic, LLC
56 Whitehall Ave
Mystic
CT
06355
(860) 572-8282
Naugatuck Health &
Wellness Center
799 New Haven Rd
Naugatuck
CT
06770
(203) 723-5636
972 A W Main St
New Britain
CT
06053
(860) 827-0745
972 W MAIN ST
NEW BRITAIN
CT
06053
(860) 827-0745
972A W Main St
New Britain
CT
06053
(860) 821-0745
100 Grand St
New Britain
CT
06050
(860) 224-5011
Concentra Medical
Centers
370 James St Ste
304
New Haven
CT
06513
(203) 503-0482
Minor
Emerg/Urgent
Care C
Concentra Urgent
Care
370 James St Ste
304
New Haven
CT
06513
(866) 944-6046
Hospital General/Acute
Hospital of Saint
Raphael
1450 Chapel St
New Haven
CT
06511
(203) 789-3000
Occupational
Medicine Center
St. Raphael's
Occupational Health
Plus
175 Sherman Ave
New Haven
CT
06511
(203) 789-3392
Hospital General/Acute
Yale New Haven
Hospital
20 York St
New Haven
CT
06510
(203) 688-4242
Hospital General/Acute
Yale New Haven
Hospital
60 and 40 Temple
St
New Haven
CT
06510
(203) 688-4444
CT, NEW
LONDON
CT, NEW
HAVEN
Minor
Emerg/Urgent
Care C
CT, HARTFORD Occupational
Medicine Center
CT, HARTFORD Occupational
Medicine Center
CT, HARTFORD Occupational
Medicine Center
CT, HARTFORD Hospital General/Acute
CT, NEW
Occupational
HAVEN
Medicine Center
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
Concentra Medical
Centers
Concentra Medical
Centers
Occupational Health
Centers of The
Southwest, PA
The Hospital of
Central Connecticut
CT, NEW
HAVEN
Hospital General/Acute
Yale New Haven
Hospital
789 Howard Ave
New Haven
CT
06519
(919) 363-1957
Primary Care
Clinic
United Community &
Family Services
400 Bayonet St
New London
CT
06320
(860) 892-7042
CT, LITCHFIELD Primary Care
Clinic
Candlewood Valley
Health Center
30 Park Ln E
New Milford
CT
06776
(860) 355-0971
CT, LITCHFIELD Hospital General/Acute
New Milford Hospital
21 Elm St
New Milford
CT
06776
(860) 355-2611
Medworks, LLC
375 E Cedar St
Newington
CT
06111
(860) 667-4418
Urgent Care Center
LLP
163 Universal Dr N
North Haven
CT
06473
(203) 298-4600
Norwalk Hospital
24 Stevens St
Norwalk
CT
06850
(203) 852-2000
Norwalk
CT
06850
(203) 852-2417
Urgent Care Center
LLP
677 Connecticut Ave Norwalk
CT
06854
(203) 298-4600
Concentra Medical
Centers
10 Connecticut Ave Norwich
CT
06360
(860) 859-5100
Minor
Emerg/Urgent
Care C
Concentra Urgent
Care
10 Connecticut Ave Norwich
CT
06360
(866) 944-6046
Primary Care
Clinic
Conncare Inc.
111 Salem Tpke Ste
Norwich
8
CT
06360
(860) 425-8701
Primary Care
Clinic
United Community &
Family Services
47 Town St
Norwich
CT
06360
(860) 442-4319
Hospital General/Acute
William W Backus
Hospital
326 Washington St
Norwich
CT
06360
(860) 889-8331
CT
06475
(860) 388-5881
CT, NEW
LONDON
CT, HARTFORD Occupational
Medicine Center
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, FAIRFIELD Hospital General/Acute
CT, FAIRFIELD Occupational
Medicine Center
Minor
CT, FAIRFIELD
Emerg/Urgent
Care C
CT, NEW
Occupational
LONDON
Medicine Center
CT, NEW
LONDON
CT, NEW
LONDON
CT, NEW
LONDON
CT, NEW
LONDON
CT, MIDDLESEX Primary Care
Clinic
Occupational Hlth Svs
520 West Avenue
of Norwalk Hosp.
Old Saybrook Medical 633 Middlesex Tpke
Old Saybrook
Office Building
Ste 110
CT, NEW
HAVEN
Minor
Emerg/Urgent
Care C
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, WINDHAM Primary Care
Clinic
CT, HARTFORD Occupational
Medicine Center
CT, WINDHAM Hospital General/Acute
CT, FAIRFIELD Hospital General/Acute
CT, FAIRFIELD
CT, FAIRFIELD
Stony Creek Urgent
Care Center
236 Boston Post Rd Orange
CT
06477
(203) 815-1054
Urgent Care Center
LLP
109 Boston Post Rd Orange
CT
06477
(203) 298-4600
31 Dow Rd
Plainfield
CT
06374
(860) 564-6290
440 New Britain Ave Plainville
CT
06062
(860) 747-9441
Day Kimball Hospital
320 Pomfret St
Putnam
CT
06260
(860) 928-6541
Danbury Hospital
901 Ethan Allen
Hwy Ste 105
Ridgefield
CT
06877
(203) 244-2400
Plainfield Health
Center
Alliance Occupational
Health
Occupational
Medicine Center
Griffin Hospital
Occupational Medicine 100 Commerce Dr
Center
Shelton
CT
06484
(203) 944-3718
Minor
Emerg/Urgent
Care C, Primary
Care Clinic
Huntington Walk in
Center
Shelton
CT
06484
(203) 225-6020
887 Bridgeport Ave
CT, HARTFORD Occupational
Medicine Center
Connecticut
Occupational Medicine 2800 Tamarack Ave South Windsor
Partners, LLC
CT
06074
(860) 647-4796
CT, HARTFORD Occupational
Medicine Center
Connecticut
2800 Tamarack Ave
Occupational Medicine
South Windsor
Ste 001
Partners, LLC
CT
06074
(860) 647-4796
Corpcare Occupational 2800 Tamarack Ave
South Windsor
Health
Ste 001
CT
06074
(860) 647-4796
Urgent Care Medical
Associates LLC
CT, HARTFORD Occupational
Medicine Center
CT, NEW
Minor
HAVEN
Emerg/Urgent
Care C
CT, HARTFORD Hospital General/Acute
CT, TOLLAND
Hospital General/Acute
CT, FAIRFIELD Occupational
Medicine Center
CT, FAIRFIELD Hospital General/Acute
The Hospital of
Central Connecticut
Johnson Memorial
Hospital
Concentra Medical
Centers
Stamford Hospital
900 Main St S Bldg
2
Southbury
CT
06488
(203) 885-0814
81 Meriden Ave
Southington
CT
06489
(860) 276-5000
201 Chestnut Hill Rd Stafford Sprgs. CT
06076
(860) 684-4251
15 Commerce Rd
3rd Floor
1351 Washintgon
Blvd
Stamford
CT
06902
(203) 324-9100
Stamford
CT
06902
(203) 621-3700
CT, FAIRFIELD
Hospital General/Acute
Occupational
Medicine Center
Minor
Emerg/Urgent
Care C
Minor
Emerg/Urgent
Care C
Stamford Hospital
30 Shelburne Rd
Stamford
CT
06904
(203) 276-1000
Concentra Medical
Centers
555 Lordship Blvd
Stratford
CT
06615
(203) 380-5945
Concentra Urgent
Care
555 Lordship Blvd
Stratford
CT
06615
(866) 944-6046
MED Now Family Walk1040 Barnum Ave
In
Stratford
CT
06614
(203) 377-5733
Occupational Health
Centers of The
Southwest, PA
555 Lordship Blvd
Stratford
CT
06615
(203) 380-5945
CT, LITCHFIELD Hospital General/Acute
Charlotte Hungerford
Hospital
540 Litchfield St
Torrington
CT
06790
(860) 496-6666
CT, LITCHFIELD Occupational
Medicine Center
Concentra Medical
Centers
333 Kennedy Dr Ste
Torrington
202
CT
06790
(860) 482-4552
Concentra Urgent
Care
333 Kennedy Dr Ste
Torrington
202
CT
06790
(866) 944-6046
Endoscopy Center of
Northwest Ct
245 Alvord Park Rd
Ste B
Torrington
CT
06790
(860) 489-2190
CT, LITCHFIELD Occupational
Medicine Center
Occupational Health
Centers of The
Southwest, PA
333 Kennedy Dr Ste
Torrington
202
CT
06790
(860) 482-4552
CT, LITCHFIELD Occupational
Medicine Center
St. Francis
Occupational Health
1598 E Main St
CT
06790
(860) 482-3467
CT, FAIRFIELD
Primary Care
Clinic
First Aid Immediate
Care
900 White Plains Rd Trumbull
CT
06611
(203) 261-6111
Primary Care
Clinic
Conncare Montville
80 Norwich New
London Tpke
Uncasville
CT
06382
(860) 848-1298
31 Union St
Vernon
CT
06066
(860) 646-1222
Route 83
Vernon
CT
06066
(860) 872-0501
31 UNION ST
VERNON
ROCKVILLE
CT
06066
(860) 872-0501
CT, FAIRFIELD
CT, FAIRFIELD
CT, FAIRFIELD
CT, FAIRFIELD
Occupational
Medicine Center
Minor
Emerg/Urgent
Care C
Minor
CT, LITCHFIELD
Emerg/Urgent
Care C
CT, LITCHFIELD
CT, NEW
LONDON
CT, TOLLAND
CT, TOLLAND
CT, TOLLAND
Hospital General/Acute
Hospital General/Acute
Minor
Emerg/Urgent
Care C
Rockville General
Hospital
Rockville General
Hospital
Promptcare Walk in
Urgent Care
Torrington
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
CT, NEW
HAVEN
Occupational
Medicine Center
Concentra Medical
Centers
900 Northrop Rd
Wallingford
CT
06492
(203) 949-1534
Minor
Emerg/Urgent
Care C
Concentra Urgent
Care
900 Northrup Rd
Wallingford
CT
06492
(866) 944-6046
Occupational
Medicine Center
Concentra Medical
Centers
8 South Commons
Rd
Waterbury
CT
06704
(203) 759-1229
Minor
Emerg/Urgent
Care C
Concentra Urgent
Care
8 S Commons Rd
Waterbury
CT
06704
(866) 944-6046
Hospital General/Acute
St. Mary's Hospital
160 Robbins St
Waterbury
CT
06708
(203) 755-6663
Hospital General/Acute
St. Mary's Hospital
56 Franklin St
Waterbury
CT
06706
(203) 709-6000
Hospital General/Acute
Waterbury Hospital
64 Robbins St
Waterbury
CT
06708
(203) 573-7280
Emergi Care of
Watertown
694 Straits Tpke
Watertown
CT
06795
(860) 274-7571
West Hartford
CT
06107
(860) 521-8700
Willimantic
CT
06226
(860) 456-9116
Windsor
CT
06095
(860) 298-8442
1080 Day Hill Rd
Windsor
CT
06095
(866) 944-6046
1080 Day Hill Rd
Windsor
CT
06095
(860) 285-8295
100 Deerfield Rd
Windsor
CT
06095
(860) 714-9444
340 Broad St
Windsor
CT
06095
(860) 688-8888
Minor
Emerg/Urgent
Care C
CT, HARTFORD Occupational
Medicine Center
CT, WINDHAM Hospital General/Acute
CT, HARTFORD Occupational
Medicine Center
Minor
CT, HARTFORD
Emerg/Urgent
Care C
CT, LITCHFIELD
CT, HARTFORD Occupational
Medicine Center
CT, HARTFORD Occupational
Medicine Center
Occupational
CT, HARTFORD Medicine Center,
Primary Care
Clinic
Brookview Health Care
130 Loomis Dr
Facility
Windham Community
112 Mansfield Ave
Memorial Hospital
Concentra Medical
1080 Day Hill Rd
Centers
Concentra Urgent
Care
Occupational Health
Centers of The
Southwest, PA
St. Francis
Occupational Health
Total Medical Care
CT, NEW
HAVEN
Primary Care
Clinic
Wolcott Health &
Wellness Center
503 Wolcott Rd
Wolcott
CT
06716
(203) 879-7900
A.I.M. WorksTM
Express Scripts Pharmacy Program for Injured Workers
As part of our workers compensation medical management services, we ask injured workers to use a
pharmacy program through Express Scripts, Inc. (ESI). ESI is a pharmacy benefit management company
that is uniquely set up to provide prescription medications for work-related injuries.
Injured employees will be notified by mail about the pharmacy program and how it works shortly after
their claim has been approved. They will also receive a prescription identification card; the card is valid
only for prescriptions related to the specific, approved work injury. Injured employees will be asked
to use an Express Scripts affiliated pharmacy to fill their injury-related prescriptions.
Express Scripts also offers a mail service program, which employees will find convenient for refilling
maintenance (long-term) prescription medications. I’m sure you are familiar with the cost benefits of a
mail order prescription program, and we ask that you encourage injured workers to take advantage of
this service. Most prescriptions are filled within 48 hours of receipt and mailed directly to the injured
employee’s home. Injured employees can sign up for the mail service program through ESI by phone or
by mail.
Additional benefits of the program include 24-hour access to a registered pharmacist via a toll-free
number and an extensive network of pharmacies to choose from. Express Scripts offers significant
savings of up to 35% over fee schedules and usual and customary charges, and the program will
expedite claim processing and payment. Injured employees will incur no out-of-pocket expenses.
A list of Express Scripts affiliated pharmacies in the Northeast is included in this claim kit. Injured
workers will receive a condensed list of chain pharmacies in the network on the reverse side of their
prescription card information sheet. If their pharmacy is not on the list, they can call Express Scripts at
1-800-945-5951 to verify if their pharmacy is part of the network. While injured employees may use a
non-affiliated pharmacy, we strongly recommend they use a pharmacy within the Express Scripts
network and the mail order service to realize the program benefits.
Please call the Express Scripts Workers Compensation Service Center at 1-800-945-5951 with any
questions you may have. The toll free service is available 24 hours a day, seven days a week. As always,
thank you for working with us to enhance our claim service.
Sincerely,
Robert R. Cella
Vice President-Operations
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 800.945.5951.
AIM WORKS
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
800.945.5951.
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 888.786.9640.
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
(enter in PA field in the format YYYYMMDD)
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
NOTE: This form is not valid in the state of Ohio. For all other states, liability of a workers’ compensation claim is not assumed
based on the dispensing of medication(s) to a patient.