WORKERS' COMPENSATION (CA) 

• Group #:  FHDA-01 (self-funded)
• District Contacts: 

Human Resources:  650-949-6224
Foothill Health Services:  650-949-7243 or 650-949-7117
De Anza Health Services:  408-864-8732

• Kaiser On-The-Go Contact Information
• Workers' Compensation Notice
• Employee/Student Employee Injury Claim Process
• Claims Administration:

Sedgwick CMS Company
P. O. Box 14535
Lexington, KY 40512-4535
Phone: 877-809-9478
Fax: 859-280-4950

Injured workers whom have been treated by U.S. HealthWorks should continue to be treated by the physicians at U.S. HealthWorks. New injuries will be directed to Kaiser Occupational Medicine Clinic effective May 1, 2017. Please find the clinic information below:  

Kaiser ON-THE-JOB Occupational Health Center

10050 N. Wolfe Road

Suite SW1 - 190

Cupertino, CA 95014

Phone: (408) 236 - 6160

General phone number: (800) 464 - 4000

Monday – Friday:  8:30am - 5:00pm

Closed for lunch: 12:30pm - 1:30pm

Closed weekends and Holidays

Additional Information

Facts about Workers' Compensation

Workers' Compensation Medical Leave Allowance Earning Codes : codes 254, 255,and 256 (Applicable only for contract employees)

FORMS:

To receive treatment at Kaiser Occupational Medicine Clinic- FHDA's designated WC clinic:

WC Treatment Authorization Form

WC Treatment Clinic Information(Cupertino Location)

WC Treament Clinic Information(Within California) Last Updated: Sep'24

To be completed by the injured worker (The worker may be assisted by Benefits Unit staff):

State of California Employer's Report Form (Form 5020)

Workers' Comp Report of Injury Form

DWC-1

To be completed by the injured worker's supervisor:

Supervisor's Claim and Safety Report