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Home My WebLink About106.018 - FC-11, Medical Service Order (MSO) and Occupational Health Providers List ADMINISTRATIVE MANUAL FORMS 106.018 MEDICAL SERVICE ORDER (MSO) / OCCUPATIONAL HEALTH PROVIDERS LIST (FC-11) EFFECTIVE: SEPTEMBER 2008 Current Revision Date: 04/26/21 Next Revision Date: 04/26/24 Author’s Name/Rank: Brad Dandridge, Battalion Chief Review Level: 1 Administrative Support: Evelyn Yin-Zepeda, Management Analyst II PURPOSE This policy ensures proper documentation of all injuries sustained during the course of employment with the City of Fresno (City) Fire Department (FFD or Department). APPLICATION The Medical Service Order Form (MSO) contains authorization for medical care for an injury or illness incurred by a member during the course of his/her employment with the City and includes an up-to-date list of Occupational Health Care Providers utilized by the City of Fresno. OPERATIONAL POLICY The Medical Service Order Form (MSO) should be completed prior to member receiving medical treatment and used when seeking first aid or medical treatment at a health care facility for an on-the-job injury or illness. In cases of an emergency involving serious injury, the form can be completed after treatment. OPERATIONAL GUIDELINE When a member incurs a job-related injury or illness, which requires medical treatment by a licensed health care provider, an MSO will be completed. Note: In cases of exposure to potentially hazardous environmental factors, when the only medical treatment a member will receive is a screening test to determine the extent of exposure, an MSO shall be completed. Any billings for such medical screening procedures received by the member will be forwarded immediately to the Safety and Wellness Officer at Headquarters. PROCESS Procedures 1. When a member experiences an on-the-job injury or illness, the company officer or supervisor should refer the member to his/her pre-designated physician. Note: To be valid, the pre-designated physician election must be in writing (Administrative Manual, Section 106.022, Employee Physician Pre-Designation, Form FC-19 (FC-19)) and on file in Risk Management prior to the injury or illness. In the event the member does not have a pre-designated personal physician on record, a list of approved Occupational Health Care Providers is included in this form. Note: Hospital emergency rooms are NOT to be used, except in the case of a serious or life-threatening on-the-job injury or illness. 2. A completed MSO (FC-11) will be automatically generated and emailed to the injured worker upon the supervisor’s completion of the Administrative Manual, Section 106.015, Supervisor’s Report of Injury, Form FC-06 (FC- 06) in the Department’s Records Management System (RMS). The member should print it and present it to the treating physician or medical facility. In all cases, the MSO must be received by the physician or medical facility. A completed FC-11, with completed FC-06 and Administrative Manual, Section 106.020, Employee Claim for Workers’ Compensation Benefits, Form FC-17 (FC-17), should be submitted through the RMS prior to the end of the shift in which the injury occurred. In the event this option is not available, forms may be accessed through the File Center / Manuals, Procedures, and Forms in (Learning Management System). The completed forms may be scanned and sent electronically, or hand delivered to the Safety and Wellness Office at Headquarters. Note: Telephone contact with the Safety and Wellness Officer should be attempted prior to sending any electronic communications to ensure both parties are aware notification is occurring in this manner. Section 106.018 Page 2 of 6 3.Each physician and medical facility treating the member should receive an MSO. However, if a member requires more than one visit to the same physician or medical facility for treatment of the same injury or illness, only one MSO should be issued. 4.If a member is off duty and requires medical care for a job-incurred injury or illness, he/she must obtain an MSO prior to receiving treatment, unless it is an emergency and immediate attention is critical. The MSO may be obtained from the company officer at any fire station or from the Safety and Wellness Officer at Headquarters. See Administrative Manual, Section 110.003, On-the-Job Injury Reporting, for related information. Emergencies Involving Serious Injuries When emergency medical treatment is required, the member should be referred to the nearest medical facility or approved occupational health provider for immediate treatment. In such cases where an MSO is not completed prior to treatment, the supervisor should complete the MSO and forward a copy to the Safety and Wellness Officer at Headquarters, with a note requesting a copy be mailed to the attending physician or medical facility. Instructions for Completing the MSO A completed MSO (FC-11) will be automatically generated and emailed to the injured worker upon the supervisor’s completion of the FC-06 in the RMS when indication that medical treatment at a health care facility for on-the-job injury or illness is needed. If the RMS is unavailable, access the FC-11 through the File Center in LMS and follow the directions below. Provide a copy to the injured worker and forward a copy to the Safety and Wellness Officer at Headquarters. The MSO should be completed as follows: 1.Enter the injured member’s (employee’s) name in full. 2.Enter the member’s social security number. 3.Enter the date of the injury. 4.Enter the employer – City of Fresno, Fire Department 5.The company officer should sign on the authorization representative line. Section 106.018 Page 3 of 6 6.The preferred provider physician’s name and/or facility providing treatment to the member. 7.Enter the address of the physician or facility. 8.Enter the city of the physician or facility. 9.Enter the telephone number of the physician or facility. Note: In the event of a recurrence, a note stating the original date of injury is to be written on the bottom of the MSO, and a copy forwarded to the Safety and Wellness Officer at headquarters. In all cases, except emergencies, the member should obtain the MSO, completed by the supervisor, prior to receiving any medical treatment. The MSO should only be issued if the member is seeking medical treatment. The MSO is not to be issued on a contingency basis. Distribution Original -Presented to physician or medical facility by the member. Copy -To the Safety and Wellness Officer at headquarters. INFORMATION A Supervisor’s Report of Injury (FC-06) and an Employee's Claim for Workers' Compensation Benefits form (FC-17) must also be completed (except as noted in policy). FC-17 must be provided to a member who is seeking medical treatment or hospitalization within one working day. DEFINITIONS This section intentionally left blank. CROSS-REFERENCES Administrative Manual Section 106.015, Supervisor’s Report of Injury (FC-06) Section 106.020, Employee Claim for Workers’ Compensation Benefits (FC-17) Section 106.022, Employee Physician Pre-Designation Form (FC-19) Section 110.003, On-the-Job Injury (OJI) Reporting Section 106.018 Page 4 of 6 management FC-11 AUTHORIZATION FOR MEDICAL CARE/CALIFORNIA MSO Form (For use by employers to refer to Preferred Provider Physicians) EMPLOYEE’S NAME SOCIAL SECURITY NUMBER DATE OF INJURY EMPLOYER City of Fresno, Fire Department AUTHORIZATION REPRESENTATIVE PREFERRED PROVIDER PHYSICIAN ADDRESS CITY TELEPHONE TO PREFERRED PROVIDER PHYSICIAN: Immediately send doctor’s first report of work injury and this authorization form to: Post Office Box 9783 Fresno, CA 93794-9783 Tel 1 (800) 500-3744 Fax (559) 277-4961 Your employer has recommended a local physician to treat your injury or illness. If you wish to change doctors, contact your American All-Risk Loss Administrators representative. You are entitled to be treated by your own personal physician only if you’ve notified your employer in writing before the injury. Su Patrón ha recommendado a un medico local para darle tratamiento medico por su lesion o enfermedad. Si usted desea cambiar de doctores, contacte a su representante de American All-Risk Loss Administrators. Usted tiene derecho a recibir tratameinto medico de parte de su medico privado, solo si usted ha notificado pro escrito antes de su accidente. Section 106.018 Page 5 of 6 ♦ r claims management First Treatment Sites St. Agnes Occupational Health Center St. Agnes Hospital (ER)* 1245 E. Herndon Ave. 1303 E. Herndon Ave. Fresno, CA 93720 Fresno, CA 93720 450-7777 450-3000 Community Regional Medical Center (ER)* Clovis Comm. Medical Center (ER)* 2823 Fresno St. 2755 Herndon Ave. Fresno, CA 93721 Clovis, CA 93611 459-6000 323-4000 or 324-4000 Clovis Urgent Care Palm Medical Group 1555 Shaw Ave., Ste. 101 222 W. Shaw Ave. Clovis, CA 93611 Fresno, CA 93704 324-7001 222-9200 Concentra – Main Clinic Willow Urgent Care 7265 E. First St. #105 6721 N. Willow Ave., Ste. 101 Fresno, CA 93720 Fresno, CA 93710 431-8181 324-0911 Concentra – Madera Clinic Concentra 509 S. I Street, Ste. A 2555 S. East Ave. Madera, CA 93637 Fresno, CA 93706 673-9020 499-2400 F.I.R.M.Kaiser On The Job 6042 N. Fresno St., Ste. 101 7300 N. Fresno St., Oak 1, Bldg. T Fresno, CA 93710 Fresno, CA 93720 224-6754 448-4886 Hanford Community Medical Center (ER)* Kaweah Delta District Hospital (ER)* 450 Greenfield Ave. 400 W. Mineral King Ave. Hanford, CA 93230 Visalia, CA 93291 582-9000 624-2000 Tulare District Hospital (ER)* 869 N. Cherry St. Mercy Medical Center (ER)* 301 E. 13th St. Tulare, CA 93274 Merced, CA 95340 559-688-0821 209-385-7000 Selma Community Hospital (ER)* Kingsburg District Hospital (ER)* 1141 Rose Ave. 1200 Smith St. Selma, CA 93662 Kingsburg, CA 93638 559-891-1000 559-897-5841 Coalinga Valley Health Clinic Industrial Health Care 1145 Phelps Ave., Ste. 104 1850 Whitson St. Coalinga, CA 93210 Selma, CA 93662 (559) 935-4374 (559) 896-1414 *(ER = Emergency Room only for after business hours injuries) Updated: 11/16/15 Department Contacts: Safety and Wellness Officer - 559-621-4177 Personnel Officer, BC5 - 559-621- 4405 Communicable Disease Investigations (Reports): DICO- 559-621-4155 Section 106.018 Page 6 of 6