Massachusetts Claims Forms

Document What It Is When To Use/File
Authorization to Disclose Health Information Required authorization form under the HIPAA Privacy Rule for disclosure of health information to Cove Risk’s for the purpose a legal workers’ compensation claim. Injured employee/patient must sign this form where indicated and return to Cove Risk Services.
Claim Kit for self-insured trust members Cove Risk’s exclusive guide for employers and injured workers including forms for proper filing of claims and other necessary information pursuant to Massachusetts Workers’ Compensation Law. Whenever an injury occurs.
Doctor’s Report of Treatment Internal form we utilize to give the treating physician information on the workers’ compensation insurance carrier and to give us some early medical information on the injury. Give this form to the injured employee to bring to his/her physician.
Form 101 Employer’s First Report of Injury (LTW Cases)
Secure Form: You may fill out and submit online.For instructions click here		 This form should be completed ASAP after the injury occurs. Keep a copy of the completed form for your OSHA log and records and send a copy to the injured employee. Cove Risk Services will file the appropriate report on your behalf to the Department of Industrial Accidents as necessary in cases involving 5 or more calendar days lost from work.
Form 118 Employer’s First Report of Injury/Medical Only Claims.
Secure Form: You may fill out and submit online.For instructions click here		 This first report is sent only to Cove Risk ASAP after the injury occurs.
Form 117 Average Weekly Wage Computation Schedule using wages for the last 52 weeks prior to the date of injury, or if N/A, wages earned from the date of hire to the date of injury. Print, fill out and return to Cove Risk Services. Submit to Cove Risk when an employee is losing 5 or more calendar days and the Form 101 has been filed.
 
Return to Work Notification Follow-up form upon employee’s return to work. Fax to Cove Risk when the injured employee returns to work.
Supervisor’s Investigation Report All claims must be investigated. Internal form utilized in the investigation; should assist in preventing a recurrence of the same type of injury. Send to Cove Risk with the claim.
Job Analysis Form Provides physical job requirement details. This information is useful for physicians, physical therapists, and other members of an injured employee’s care team. Employer may also benefit from internal use of the form. May be used after an injury to assist the medical provider and medical case manager in effectuating the best treatment/rehabilitation plan to aid recovery. May also be utilized by an employer internally in tandem with a job hazard analysis.