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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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