Application Complete!

Print a Copy for Your Records

Thank you for your interest in providing services to our injured workers.  Your submitted form has been entered into our system.

The Health Care Provider Liaison will review your application and contact you. 

If you have questions about your submission or the process, please call or email us.

Phone: 867-667-5645 or toll free 1-800-661-0443

Email: [email protected]

Fax: 867-667-8740