Verification of Employment for a Workplace Injury or Illness
Injured employees should take the completed form with them on their first healthcare provider visit. The form describes the workplace injury and includes contact information for billing and submitting work status reports.
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This information is exclusively for members with Workers' Compensation access.
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Request for Healthcare Preauthorization Form
Providers treating injured employees submit this simple form to request preauthorization for healthcare services.
Bona Fide Offer of Employment Template
When the doctor clears your injured employee to return to work, use this template to issue a bona fide offer of employment that meets state requirements.
Employee Acknowledgement of Alliance Direct Contracting Program
Employees must sign this form acknowledging they understand how to receive health care in the Political Subdivision Workers’ Compensation Alliance. Available in English and Spanish.
Employee Incident Investigation Worksheet
Uncover and correct the root causes of workplace accidents to reduce the risk of them happening again.