Warren County Self Insurance

Procedure for Reporting Workers' Compensation Injury

Employee Responsibilities

1. Complete “Employee Claim” (Form C-3.0) – 2 pages
2. Complete “Limited Release of Health Information” (Form C-3.3) – 1 page
3. Complete “Authorization to Obtain Information” (WC Form 5) – 1 page

* The 3 forms above should be provided to your supervisor immediately.

If your injury requires medical care

This packet contains forms that you will need to take with you to the treating provider & pharmacy.

Take a copy of “Physician / Chiropractor Report” (WC Form 6) with you to each doctor visit.

Tell your doctor or hospital to send all bills to the following address. Be sure to mark the date of injury clearly on all correspondence.

Warren County Self-Insurance, 1340 State Route 9, Lake George NY 12845

If you require pharmaceuticals for this injury, take the “Injured Worker’s First Fill Prescription Information Sheet” with you to the pharmacy.

Provide your supervisor with proper medical documentation if time away from work is recommended.

If your injury requires medical treatment, the Self-Insurance Department will mail you an information packet with your claim information.

Supervisor Responsibilities

• Confirm that the employee has completed and given you the forms:
  • “Employee Claim” (Form C-3.0) – 2 pages
  • “Limited Release of Health Information” (Form C-3.3) – 1 page
  • “Authorization to Obtain Information” (WC Form 5) – 1 page
• Advise and confirm that the employee has retained forms:
  • “Claimant Information Packet” – 2 pages
  • “Physician / Chiropractor Report” – 1 page
  • “Injured Worker’s First Fill Prescription Information Sheet” – 1 page
  • “Participating Retail Pharmacies” – 2 pages
• Complete Form C-2.0 – 3 pages
• Forward the competed Employee forms (3) and the C-2.0 form to Self-Insurance.
• Notify Self-Insurance when employee returns to work OR if the employee’s condition changes