Workers' Compensation Acknowledgment Form

What RTW / workers' comp information IS confidential? While relevant, recent, work-related medical information is usually not confidential, other medical informationsuch as the individual's medical historyis confidential.

The EEOC says An employer may ask questions about an applicant's prior workers' compensation claims or occupational injuries after it has made a conditional offer of employment, but before employment has begun, as long as it asks the same questions of all entering employees in the same job category.

Will a Workers' Compensation Case Affect My Future Employment? As long as you do not badmouth your former employer, a previous workers' compensation claim should not impact your chances of being hired in the future.

Wages or salaries including retroactive wages or salaries. Total cash received by employees for commissions and draws against commissions. Bonuses including stock bonus plans. Extra pay for overtime work-see next section for exceptions.

The HIPAA Privacy Rule does not apply to entities that are either workers' compensation insurers, workers' compensation administrative agencies, or employers, except to the extent they may otherwise be covered entities.

Be factual with the information you provide. Be concise with the information you provide. Keep descriptions simple and to the point. Be sure to monitor your audit results.

A prospective employer has no right to ask whether you have had a previous workers' compensation claim. However, a prospective employer does have the right to know if you have an injury or medical condition that will impact on your ability to perform your work duties.

State your name, date of birth, social security number, and date of injury at the very beginning of your letter. Explicitly state that you were on-the-job and that you were injured while performing your duties. Elaborate on the tasks you were performing at the time of your injury. Include as many details as you can.

Payroll journal and summary. Your check book (if it's your only means of keeping records. Federal Tax Report- 941's that cover the period. State Unemployment Tax reports or individual earnings records. All overtime payroll records (charged at reduced rates)