BLOOMSBURG UNIVERSITY OF PENNSYLVANIA
WORKERS’ COMPENSATION INJURY EXPOSURE FORM
To be presented to ER registration secretary:
EMPLOYEE NAME: ____________________________________________________
SS#:
_____________________________________________________
EMPLOYER:
BLOOMSBURG UNIVERSITY OF PA
HUMAN RESOURCES & LABOR RELATIONS
134 WALLER ADMINISTRATION BUILDING
400 EAST SECOND STREET
BLOOMSBURG, PA 17815
TELEPHONE:
CONTACT PERSON:
570-389-4151
Tanya Bombicca
For Emergency Services Information:
There is a list of workers’ compensation panel providers on file.
Billing Information:
Send bills to:
INSERVCO INSURANCE SERVICES, INC
P.O. BOX 3899
HARRISBURG, PA 17105-3899
MEDICAL AND/OR HOSPITAL AUTHORIZATION FOR RELEASE OF INFORMATION
To whom it may concern:
Patient: __________________________________________________________
I hereby authorize you to permit INSERVCO INSURANCE SERVICES, INC./ BLOOMSBURG
UNIVERSITY, or their designated representative, to examine, make or be furnished with copies of any
records or information, x-rays and x-ray reports in connection with any illness or injury requiring
confinement and/or treatment by you.
I agree that a copy of this authorization shall be considered as effective and valid as the original.
Date: _______________________
Signed: ____________________________
Address: __________________________
04/11