Page | 19 WORKERS’ 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* bcharmai@nova.edu-(Email) 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. PO Box 948399 | Maitland| FL 32794-8399 1-866-291-0194 | 407‐660‐5600 | Fax: 217‐477‐6946 | FICURMAmail@ccmsi.com
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