STUDENT ACCIDENT CLAIMS
1. When a student (see instructions for the work-study program at the bottom of the page) has an accident on campus, the student should be given the attached Student Accident paperwork. The injured student is responsible for completing the Student Accident Report, Commercial Traveler’s Claim Form and HIPAA Authorization. All data must be completed and returned to the regional contact responsible for handling student accident claims so that claims can be submitted to the insurance carrier. IF THE INJURY IS A NEEDLE STICK, EXPOSURE TO BLOOD BORNE/AIR BORNE PATHOGEN OR EXPOSURE TO BODY FLUIDS PLEASE SEE INSTRUCTIONS FOR GENERAL LIABILITY CLAIMS 2. The regional contact will fax the forms to Commercial Travelers, Charlie Vaught at Gregory & Appel and Amy Christianson at Central Office. FAX THE STUDENT ACCIDENT PAPERWORK IMMEDIATELY AFTER RECEIVING IT. DO NOT WAIT UNTIL BILLS ARE RECEIVED TO REPORT THE CLAIM. 3. Any medical bills that are received regarding the student’s accident must be forwarded to Commercial Travelers, Charlie Vaught, and Amy Christianson. Bills must be itemized in order to be paid (HCFA, UB-92). An itemized bill must contain: patient’s name, date of service, type of service (procedure), nature of condition being treated (diagnosis), provider’s name, provider’s address and provider’s tax identification number. It is the student’s responsibility to obtain an itemized bill. Examples of a HCFA and UB-92 are attached to the Student Accident Paperwork. 4. A copy of all forms and medical bills must be kept on file by the region submitting the claim. 5. If an eligible expense incurred reaches the $2,500 maximum under the Commercial Travelers plan, the claim will be turned over to the College’s general liability carrier for consideration. The regional contact will be notified once a claim has reached the $2,500 maximum. 6. The Student Accident forms are in the Forms section of Infonet under “Student Accident Report”. The forms are also located on Campus Connect in the Health & Wellness section of the Campus Life tab. Students in Work-Study Program *Students involved in work-study programs are considered employees if they are on the job when an accident/illness occurs. SEE INSTRUCTIONS ON FILING A WORKER’S COMPENSATION CLAIM *Students involved in work-study programs are considered students at all times other than when on the job. Contact Information Ivy Tech Office - of the President: Amy Christianson Broker: Gregory & Appel Charlie Vaught Claims (First $2,500): Commercial Travelers Mutual Insurance Company
Phone: 317.921.4853
Fax: 317.921.4707
Phone: 317.686.6449
Fax: 317.634.6629
Phone: 800.756.3702
Fax: 315.797.0195
STUDENT ACCIDENT PAPERWORK
The College provides accident insurance, with a specified maximum, for injuries sustained while enrolled and participating in a College course or College-sponsored activity. Intramural and recreational sports are excluded from coverage. Examples of covered accidents include, but are not limited to, the following: Cutting a finger while chopping an onion in culinary arts class, Getting a fleck of metal in the eye while welding in auto body repair class, Twisting an ankle while lifting a patient in nursing class. If the injury is a needle stick, exposure to blood borne / air borne pathogen or exposure to body fluids, please see an Ivy Tech employee/security guard for General Liability paperwork. If the injury occurred while conducting duties as a work-study, please see the regional Human Resources department for worker’s compensation paperwork.
If a student is injured while participating in a College course or College-sponsored activity, the following steps MUST be followed:
1. NOTIFY THE INSTRUCTOR OR IVY TECH STAFF IMMEDIATELY. 2. Complete the Student Accident Report, Commercial Traveler’s Claim Form and HIPAA Authorization and submit it to the instructor or the person in charge of handling the regional student accident claims at that location. All forms must be complete and signed for claims to be considered for payment. Student Accident forms are located on Campus Connect in the Health and Wellness section of the Campus Life tab. 3. Submit itemized bills to the instructor or person in charge of handling the regional student accident claims. The College’s insurance carrier requires and only considers eligible expenses from an itemized bill (HCFA or UB-92). An itemized bill MUST include the following: Patient’s name, date of service, type of service rendered (procedure), nature of condition being treated (diagnosis), provider’s name, provider’s address and provider’s tax identification number. Samples of the necessary forms are attached. STATEMENTS OR PAST DUE BILLS WILL NOT BE ACCEPTED. IT IS THE STUDENT’S RESPONSIBILITY TO OBTAIN AN ITEMIZED BILL. 4. When medical treatment is required as a result of a covered injury, the following page may be given to the provider for insurance information. Not all claims are eligible under this plan. Be prepared to pay for services rendered if the claim is denied by the College’s insurance carrier. The student accident plan does not consider sickness.
PLEASE GIVE THIS SHEET TO THE PROVIDER’S OFFICE
The patient was injured on Ivy Tech’s premises or while fulfilling course requirements for an Ivy Tech class. Itemized bills MUST be sent for consideration to the insurance carrier listed below: Commercial Travelers Mutual Insurance Company Attn: Special Risk Claims 70 Genesee Street Utica, NY 13507 Toll Free: 800.756.3702 Fax: 315.797.0195 Student’s Name: ________________________________________
Policy Number: 2007M3B18
IVY TECH COMMUNITY COLLEGE OF INDIANA
STUDENT ACCIDENT REPORT (REPORT CLAIMS IMMEDIATELY – DO NOT WAIT UNTIL BILLS ARE RECEIVED)
Region
07
Name ____________________________________________________________________________________________________________ Home Address _________________________________________ City/State ___________________________________________________ Phone ________________________________________________ Date Report Completed_________________________________________ a.m. Incident Location _______________________________________ Date/Time of Incident ___________________________________ p.m. Instructor/Supervisor ________________________________________________________________________________________________ Description of Incident (how it occurred, materials/tool being handled, and what you were doing) _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Description of Injury (part of body, type of injury) _________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ First Aid Given? By? EMS Contacted? No No Yes Yes Procedure ______________________________________________________________________ Treatment Refused? No Yes
Have you paid the provider for services? No Yes **If you have paid the provider(s) directly, attach receipt(s) of payment along with the itemized bill(s). If you have not paid the provider(s), payment will be issued directly to the provider(s). Witness___________________________________________________________________________________________________________
EXPOSURE TO BLOOD BORNE/AIR BORNE PATHOGENS, BODY FLUIDS AND NEEDLE STICKS MUST BE SUBMITTED ON THE “GENERAL LIABILITY” FORM. INJURIES WHICH OCCUR WHILE PERFORMING DUTIES IN A WORK-STUDY PROGRAM FALL UNDER WORKER’S COMPENSATION. PLEASE SEE THE REGIONAL HUMAN RESOURCES DEPARTMENT. FOR ALL OTHER STUDENT INJURIES NOT INCLUDING THE ABOVE INCIDENTS: FILL OUT THE STUDENT INJURY REPORT, HIPAA FORM, AND COMMERCIAL TRAVELERS RELEASE AND SUBMIT THE PAPERWORK TO THE REGIONAL CONTACT RESPONSIBLE FOR HANDLING STUDENT ACCIDENT CLAIMS AT THE LOCATION. THE COLLEGE’S INSURANCE CARRIER FOR STUDENT ACCIDENTS IS: Commercial Travelers Mutual Insurance Co. Attn: Special Risk Claims 70 Genesee Street Utica, NY 13502 Fax: 315.797.0195 Instructor/Staff Signature _________________________________________________________________ Date________________________
Student Signature ________________________________________________________ Date ___________________
IVY TECH COMMUNITY COLLEGE OF INDIANA AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I, [Print Name] hereby authorize the disclosure of my protected health information as set forth below.
Entities Authorized to Provide and Receive Information The following entity(ies) may disclose my protected health information to Rae Lynn Prouse/Charity Shanks/Leslie King AND Kelly Rickard and Amy Christianson at Ivy Tech Community College of Indiana for the purpose of making inquiries and resolving questions and disputes about worker’s compensation claims, general liability claims, or student accident claims which occurred while at Ivy Tech Community College of Indiana: is/are the person(s)/organization(s) authorized to provide the information. Description of Information Specific description of information to be used or disclosed (including date(s), type of service):
Expiration of Authorization This authorization will expire use or disclosure). (indicate date, or an event that relates to you or to the purpose of the
— Y OUR RIGHTS — This authorization is voluntary and I understand that I may revoke this authorization at any time prior to its expiration date by notifying the entity(ies) described above who are authorized to disclose my health information in writing, but the revocation will not have any effect on any actions taken in reliance of this Authorization or relating to the use or disclosure of the protected health information that the entity took before it received the revocation. I understand that I am not required to sign this authorization to become eligible or to receive my health care benefits (enrollment, treatment, or payment). I understand that the information that is used or disclosed in accordance with this authorization may be redisclosed by the receiving entity and may no longer be protected by federal or state privacy laws. Your Signature or Your Representative's Signature
Signature
Date
Printed Name of Participant Printed Name of Representative (if applicable)
Address Relationship of Representative to Participant
YOU MAY REFUSE TO SIGN THIS AUTHORIZATION