Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template Page 4
Download a blank fillable Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Dfs-F2-Dwc-1 - First Report Of Injury Or Illness Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9WORKERS’ COMPENSATION TREATMENT AUTHORIZATION FORM
This is a Worker’s Compensation Treatment Authorization Form. This Form is not a guarantee of
eligibility or compensability for Workers’ Compensation Benefits.
To be completed by employer (please print)
Account Number: F45
Employer Name: ____Nova Southeastern University___________________________
Employer Address: __3301 College Avenue, Ft. Lauderdale, Florida 33314________
Employee Name: ________________________________________________________
Social Security Number: ___________________ Date of Injury: __________________
Type of Injury: _________________________________________________________
Body Part Injured: ____ __________________________________________________
Supervisor issuing form: __Charmaine Beckford (T) 954-262-5404* 954-262-6860-(F)
Supervisors: Please give this completed form to the injured employee to take with them to the
physician.
This form is for one time use, only on this date ___________.
Providers:
You must call Cannon Cochran Management Services, Inc. toll free at
1-866‐291‐0194 prior to any additional treatment/admission or referral, other than an
emergency. In an emergency, notification to CCMSI is required within 24 hours.
Send Medical Bills To:
Cannon Cochran Management Services, Inc.
‐660‐
‐477‐
1-866‐291‐
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business