Scenario 3- Employee sustains a reportable injury requiring medical
treatment
1) Take employee to medical provider for treatment
2) Employee completes DWC1
form
3) Report incident to Cambridge using the 5020
report form.
(800) 379-5726 *Location Harmony/ALTIM then your entity name
4) Complete, file, and fax a copy to Harmony Skilled
Network (805) 579-1815 of the:
Claims Shadowing Fax Cover Sheet
5020
Employer's Report of Occupational Injury or Illness
DWC1 Workers'
Compensation Claim Form
Supervisors/Employees
Incident Report Form
Witness Report Form
(if applicable)
Doctors Restrictions
Doctors First Report
Red Flags, performance issues etc. (if it's a disputable claim)
Any updated doctors reports and work restrictions
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