Signatures are required for the processing of the claim and medical billing. The pre-filled forms are included in your Service Now ticket.
Forms to be completed by the Employee that was injured on the job.
- Form PECD 1
- Form AR-N
- Form N Acknowledgement
Form to be completed by the Manager of the injured worker.
4. Form PECD 2
Return signed forms to: wc.claims.public.employee.claims@arkansas.gov
Form Description & Instructions
- Form PECD 1 – The employee must complete the last 10 questions (beginning with “Who Selected doctor”), employee must sign and date.
Example: Copied from Form PECD 1
2. Form AR-N is a Two-sided form with signatures on both sides:
- (Front Side) Employee’s Notice of Injury– the employee must sign and date.
- (Back Side) Employer’s Notice to Employee– the employee must sign and date.
Example: Copied from Form AR-N (front side):
Example: Copied from From AR-N (back side):
3. Form N Acknowledgement – Employee complete, sign, and date. Download the blank form here.
Form to be completed / reviewed by the Manager of the injured employee:
4. Form AR PECD 2 – The supervisor must complete questions 4-10 and sign and date the form, before returning it to PECD.
These are time sensitive documents. Please return the completed forms to PECD within 3 business days from receipt of the Service Now ticket.
Return signed forms to: wc.claims.public.employee.claims@arkansas.gov
If paperwork is not submitted within 30 days of the injury, the claim will automatically be closed.
Additional Forms: Workers may also receive:
- A copy of their First Report of Injury or Illness Report
- A copy of the Company Nurse – Report of Incident
- An Optum Temporary Prescription Card – To find a network pharmacy call 1-866-599-5426. If you need a prescription filled for a work-related injury or illness, go to an Optum Tmesys network pharmacy. Give them this temporary card and the pharmacist will fill your prescription at low or no cost to you. If you did not NOT receive your temporary prescription card, please contact the UAMS Case Worker: Lorna Potaka-Osborne by email or phone: 501-603-1665
Please review these to ensure they are correct and provide any updates to your PECD claim specialists.