What to do if you are injured

at work and need medical

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Employee Report of Injury

After notifying your supervisor and contacting Risk Management at 436-

1760 or 436-1767complete this form. Send to RM within 48 hours of

your injury.

If the injury report is not received in our office within 72 hours of your

injury you will be required to come into Risk Management and complete

the form.

click on lps.org to take you to the website to get this form. The form

number is in the top left hand corner.

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This form can be found on

Nebraska workers’ compensation law states you have the right to choose a physician who has a record of treating you or an immediate family member prior to your injury.

If you do not have a record of treatment with a physician or your physician does not take workers’ compensation you will then need to be evaluated at one of the district’s designated treatment facilities.

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Employee Choice or Change of Doctor

FormThis form should be completed prior to seeking medical treatment. Be sure to complete Part A and Part B

and turn in with your Employee Report of Injury.

Click on lps.org to take you to the website to get this form. The form number is in the top

left corner

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Release to Return to WorkEach time an employee is evaluated by a physician for a work injury they will

need a new release.

Custodians should take the release to CTS first and CTS will send the release

to Risk Management. All other employees should bring or fax the

release to Risk Management. It is your responsibility to make sure Risk Management receives a copy.

You will not be allowed to return to work without a release.

As tolerated is not accepted on a release

Employee should sign release stating they are aware that their restrictions apply at work and at

home.

Click on lps.org to take you to the website to get form RM0005. The form

number is in the top left corner

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When you report your injury to Risk

Management and are not going to your

physician, you will be given the phone

number for Madonna Fit for Work so you

can call and an appointment time will be scheduled at one of these facilities.

If it is during regular business hours do not

contact these facilities to make your

own appointment.

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After Hours Care

Urgent Care at Life Pointe

7501 S. 27th St.M-F 8 a.m. – 8 p.m.

Sat. & Sun. 9 a.m. to 5 p.m.

481-6343

Heartland Urgent Care965 South 27th Street, Suite DM-Sat. 8 a.m. – 8 p.m.Sun. 10 a.m. – 6 p.m.

477-3505

Fallbrook Family Health Center755 Fallbrook Blvd., Suite 100M-Th 7 a.m.- 7 p.m. Fri. 7 a.m.- 5 p.m.Sat. 9 a.m. to noon

441-3575

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If you have an injury after hours notify your

supervisor of your injury.

You may go to one of these facilities for treatment or

an emergency room if the injury warrants treatment there.

Please review the HR#2 it provides information on

workers’ compensation and

what is expected from you and what you can expect when filing a

claim.

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Single click on left side of mouse to go to next slide

Single click on left side of mouse to go to next slide

How to access all Risk

Management Forms

Go to the lps.org

webpage and type the word

“forms” in the keyword

box

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In the drop down box find Risk Management, hit enter

On the website click on the form you want and print.

If you have any questions regarding this process

please contact Risk Management

at 436-1760 or 436-1767