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ldenny@cityblm.org

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Submit Your Doctor's Note

Instructions:

Step 1. Complete the information below.

Step 2. If you have restrictions, the restrictions must be listed on the doctor’s note.

Step 3. Attach your doctors note and click Submit. This form and your document(s) will be sent to the appropriate group in HR.

Step 4. HR will notify your department. 

Department

Is This A Work-Related Injury?

Do you currently have more than one open injury or illness that has already been reported to HR (Work Comp or personal)?
 
If yes, please indicate which injury or illness this doctor’s note or release applies to. (You may list the date of injury or a brief description such as “right knee.” Please do not include a diagnosis or medical details.)
 
If no, please type N/A

Upload Doctor's Note

Click Here to Upload
-------If Work Comp------ 
If you have received bills for your work comp injury, you can submit them on this form. 
 
Please make sure the medical provider has PMA listed as the payer and has your work comp claim number.
 
If you have bills that are for other specialty providers (ex. anesthesiologist), your provider may not have provided the correct billing information to them.
 
PMA Customer Service Center
PO Box 5231
Janesville, WI 53547-5231
Phone: 888-476-2669
Fax: 800-432-9762
 

Upload Work Comp Bill, if applicable.

Click Here to Upload