Authorization for Medical Treatment - Illinois State
[pic] |Authorization for Medical Treatment | |
| | | |
|Date | | |
|Employee Name | |Date of Birth | |
|Type of Service | Treatment of Work Related Injury / Illness | Evaluation of Work Related Injury/ Illness (if |
| | |required by WC) |
|Company Name |ILLINOIS STATE UNIVERSITY |
|Company Address |Campus Box 1320, 202 NSB |
|City |Normal |State |IL |Zip |61790 |
| |
|Supervisor or Appointed Individual Authorizing Fiscal Responsibility: |
|Print Name Here | |Phone | |
|Signature | |
|OSF St. Joseph Treatment Hours and Locations |
| |
|[pic] |Occupational Health Center |
| |1505 Eastland Dr. |
| |Normal , IL 61761 |
| |Phone (309)661-6270 |
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