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Supervisors medical treatment form 2026

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The document outlines the procedures for reporting and managing workplace injuries at NC State University. It includes a Supervisor’s Medical Treatment Authorization form that must be completed by supervisors and medical providers, detailing patient information, treatment provided, work status, and follow-up appointments. It also provides contact information for HR Benefits and Environmental Health & Safety, authorized treatment facilities in Wake County, and instructions for pharmacies regarding prescription processing for injured employees.

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Click ‘Get Form’ to open the Supervisor’s Medical Treatment Authorization form in the editor.
Begin with Section A, where you will input the employee's first and last name, employee ID number, and your name as the supervisor. Ensure to sign and date this section before handing it to the injured employee.
Instruct the employee to take this form to an authorized treating medical provider. Make sure they understand which facilities are available based on their location.
Once at the medical provider, Sections B through E will be completed by them. This includes diagnosis, treatment information, work status, restrictions, and follow-up appointments.
After completion by the medical provider, ensure that the report is delivered to HR Benefits and Environmental Health & Safety within 24 hours of injury notification.

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What to do if an employee refuses medical treatment?

A CA-16 can be issued up to 48 hours after the employee has been treated. If the employee provides a medical report within 48 hours or treatment indicating the condition is work-related, a CA-16 can be issued with supervisory approval.

What evidence is required in support of a claim for work related psychiatric illness?

First and foremost, there must be a medical diagnosis of the mental health condition, supported by evidence that links the condition to the employees work. This often involves providing documentation such as medical records, psychological evaluations, and workplace incident reports.

How to get a CA-16 form?

CA-16: Where Can EA Get One? Form CA-16 is available to the supervisor once they complete their portion of Form CA-1 in ECOMP. Form CA-16 is also available to the Agency Reviewer (AR) once they complete the final review of Form CA-1 in ECOMP.

How long is the CA16 valid for?

The Form CA-16 is valid for 60 calendar days from the date of issuance. The original treating physician may wish to refer the employee for more specialized treatment or for further testing.

What is a CA16 form?

Contact HRM Contact Center with 48 hours after medical treatment or on the next business day, for issuance of CA-16 by FS WC to the medical provider.

supervisors medical treatment form

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How do I get a CA-16 form?

If this occurs, the manager should have the injured worker review and sign a waiver of medical treatment form. By having the employee sign this form it can assist in documenting an employees incident, the description of employees injury (if there was one), plus other relevant details of the incident.

How long does it take to file a CA1?

For traumatic injuries, file Form CA-1 within 30 days following the injury, and for occupational disease claims, file Form CA-2. Once you complete your portion of the claim form, it will be forwarded to your supervisor who will complete the supervisors portion before forwarding the form for review.