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Resources for Workers' Compensation Liaisons

NEW!!! Effective July 1, 2013, Alameda County is switching to York Risk Services Group as its Workers’ Compensation TPA and implementing a nurse-staffed injury hotline to report industrial injuries and initiate the filing of a workers’ compensation claim. Our new claims system is paperless.

The employee will still need to complete (and sign) a DWC-1 and return it to the supervisor, for scanning and e-mailing to the TPA.

The Form 5020 will be generated from the telephonic report, and a link to the nearly completed electronic form sent to the departmental workers’ compensation liaison for review, completion of a few fields, and electronic submission.

We encourage all departments to use this new, sustainable process.

In cases where it is not possible to report the injury through the hotline, forms still may be completed by hand and scanned or faxed to the new TPA’s Operating Services Center at 1-866-548-2637.

PLEASE SEE OUR NEW WEB PAGE “Reporting an Industrial Injury” and the power point presentation below for information on the new process. Information on obtaining medical treatment is also on the new page.

NEW!!! PowerPoint training on new claims reporting process effective July 1, 2013 (PDF - 828kb)*

Roles and Responsibilities of a Workers’ Compensation Liaison:

The following resources provide you with general information on workers' compensation benefits and your responsibility as a department liaison. Please click on the links below for the appropriate forms and instructions. Call the Risk Management Unit at 272-6920 if you need assistance.

Managing the Return to Work Process:

  • WORK STATUS REPORT (PDF - 82kb)*: For each medical appointment, the employee must bring this form to their medical provider and submit the completed form to his/her supervisor or acceptable alternative.
  • EFJA/EF5 (PDF - 473kb)*: This form is to be completed when requested by the claims adjuster to determine the injured employee’s ability to return to work. Your claims adjuster can identify resources to assist you in completing the form.
  • RETURN TO WORKFLOW CHART (PDF - 194kb)*: This flowchart shows the designation of responsibilities in returning an employee back to work.
  • Temporary Modified Work Policy (PDF - 132kb)*
  • Temporary Modified Work Plan (PDF - 97kb)*
  • TD/MODIFIED WORK TRACKING (XLS - 19kb)**: Use this form to track your employee’s time off of work or modified work assignment.

Other Resources:

  • Claremont EAP
  • DESIGNATED PHYSICIAN AND MEDICAL FACILITY (PDF - 179kb)*: For non-emergency treatment, Company Nurse will direct the employee to go to an approved occupational health facility, unless they have pre-designated a physician prior to an injury. Even with a pre-designated provider, an employee may either go to that provider or an approved occupational health facility.
  • Ergonomic Evaluations: Depending on the type of injury, an ergonomic evaluation of the employee’s worksite may be recommended. It is preferred that a preventive ergonomic evaluation be requested prior to an employee being injured. Extensive information on office ergonomics is available by clicking here.
  • Workers’ Compensation Abbreviations and Acronyms (PDF - 122kb)*: Common abbreviations and acronyms used in Workers’ Compensation claims.

* Portable Document Format (PDF) file requires the free Adobe Reader.

** Microsoft Excel (XLS) file requires the free Microsoft Excel Viewer.

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