FMCVerification form

							Franklin Medical Center
836 E. Redd Road
El Paso, Texas 79912
(915) 833-8444
FAX 833-8767
Date: ______________________              Time Employee Left Work: _______________

Employee Name: ______________________________________

Job Title: ___________________________

Employer: The University of Texas at El Paso Department:_______________________

Contact: Jackie DeArman, WC Advisor, 747-7199 or 820-5981

SERVICE(S) REQUESTED:

   o Work – Related Injury Care                Date of Injury: _________________
   o No Post-Accident Substance Abuse Testing:


Billing:
                 WC Insurance Billing:
                              University of Texas System
                              P.O. Box 68652
                              El Paso, TX 79968
             Claims Adjuster: Luann Folkner
                              (915) 747-7960 or 747-7994

Description of injury/illness:




Authorized by: ____________________________          Date: _______________________


                       PLEASE FAX WORK STATUS TO
                               915-747-8126