• WCAIS Patient Form

    WCAIS Patient Form

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  • Sent via Facsimile

    Transmission to 717-783-6365

  • Bureau of Worker's Compensation

    NCP (Notice of Compensation Payable) Department

    1171 S. Cameron Street

    Harrisburg, PA 17104-2501

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  • Dear Sir/Madam:

    We are requesting the following form(s) relative to the above-noted worker:

    • LIBC - 495 (Notice of Compensation Payable);
    • LIBC - 501 (Temporary Notice of Compensation Payable);
    • LIBC - 495 (Notice of Compensation Denial); and/or
    • LIBC - 336 (Agreement for Compensation)

     

    As instructed by your office, below please find the claimant's signed authorization which will enable you to release this information to us.

     

    Thank you for your cooperation in this matter.

     

    Sincerely,

    The Pennsylvania Pain and Spine Team 

  • Authorization to Release Workers' Compensation Records

  • I,

  • *

  • authorize Pennsylvania Pain and Spine Institute or any authorized representative thereof, to request and receive Bureau of Workers' Compensation documentation directly from the Bureau. These documents would include, but not be limited to, Notice of Compensation Payable, Temporary Notice of Compensation Payable, Judge's Decisions, and any other notices concerning my claim. Pennsylvania Pain and Spine Institute has agreed to copy me on all such requests. 

    A Photocopy of this document may be used instead of the original. 

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