AUTHORIZATION FOR INITIAL TREATMENT AND PHARMACY

State Employee Injury Compensation Trust Fund 
SEICTF 

TO BE COMPLETED BY EMPLOYEE 
If you desire program benefits, read and sign below. Benefits will not be authorized without your signature. 

I hereby authorize any physician, health care professional, hospital, or other medical care facility to provide my complete health care records to 
representatives of SEICTF (State Employee Injury Compensation Trust Fund), and/or its’ agents regarding my health and any treatment rendered. I authorize 
representatives of SEICTF and/or its’ agents to examine any and all records including but not limited to: all history and physical examinations; progress 
notes; physicians’ notes; lab reports; x-ray, MRI, CT scans, myelograms and all other diagnostic procedure reports; all consultation reports and records, in-
patient and out-patient facility records; operative reports; payment records; prescribed medications; and all notes, correspondence and records of any kind. 

In addition, I authorize the release of information relating to (1) communicable diseases such as hepatitis and the human immunodeficiency virus (HIV); 
(2) substance abuse treatment records; and (3) all mental health treatment records. 

The purpose for disclosure of these records is to allow SEICTF to evaluate my medical history and injuries in this claim and to administer benefits I may be 
eligible for under the SEICTF program. A photocopy or exact reproduction of this signed authorization shall have the same force and effect as the original. 
This Authorization for Release of Health Information is valid for one year from the date of my signature. 

I understand that I may revoke this authorization by sending a signed, written notice to SEICTF and to the healthcare provider(s) authorized to disclose my 
health information pursuant to this document. However, I also understand that any revocation will be effective only to the extent that action has not already 
been taken in reliance of this authorization. 

By refusing to sign or revoking this authorization, I understand that SEICTF will be unable to provide benefits under this program as medical records are 
required. 

Employee Signature 

Date 

EMPLOYEE: Give completed copy to your supervisor immediately after receiving treatment. 
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TO BE COMPLETED BY SUPERVISOR 

Employee Name: 

S.S. # 

 -  

 - 

Date of Injury: ___________________________   Agency: __________________________________ 

  Division/Facility:  

Description of Accident/Injury: 

Supervisor’s Signature: 

Date:  

*When completed by supervisor and physician – immediately fax or email  to SEICTF at (334) 223-6170 or (888) 827-6753 or SEICTF@finance.alabama.gov*
************************************************************************************************************************************** 
TO BE COMPLETED BY PHYSICIAN 

Diagnosis:   

Work Status:  

Activity restrictions: 

May return to full duty 

Out of work for 

 days, then return to work with restrictions (see below) 

May return to work with the following restrictions for 

 days: 

______________________________________________________________________________________________________________________________________
Physician Name (please print):  

RETURN APPOINTMENT DATE:  

 

Physician Signature:    
************************************************************************************************************************************** 
TO BE COMPLETED BY EMPLOYEE AFTER BEING SEEN BY PHYSICIAN 
I understand and agree to the recommended activity restrictions and follow up instructions. I agree I will not perform any activities outside the 
limitations either at work or home. 

 _________________                   Date:  

___________________ 

 

 

Employee Signature: ________________________________________________________________ 

 Date: _______________________ 

SEICTF FORM 3-A REV 9/13/2017 

PLEASE SEE PAGE 2 OF FORM FOR CLAIMS FILING INSTRUCTION 

PAGE 1 OF 2 

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Instructions for Submitting Claim for Payment 

Physician’s office: 

Immediately Fax this form to SEICTF at (888) 827-6753 (toll-free) or (334) 223-6170 or email to SEICTF@finance.alabama.gov.

1.
2. Give original to employee.  Have employee take original back to the employer. Keep a copy in the employee’s chart.
3. Claim filing:

A. 

B. 

For authorization and timely payment, office notes must be sent to SEICTF:  
Fax to (888) 827-6753 (toll-free) or mail to SEICTF: P. O. Box 1390, Montgomery, AL 36102. 
Send claim to: 
(1) Please file electronically to Blue Cross Blue Shield (Group 32035) - Use the WRI prefix with the employee’s 
social security number.  (Do not use the EIB number.) Do not charge co-pays or deductibles. 

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Pharmacy: 

Send claim to Blue Cross/Blue Shield of Alabama. All prescriptions must be filed electronically with BCBS by using the WRI prefix and the 
employee’s social security number. (Do not use the EIB number.) Please use BIN# 004915, group number 32035 and in the PCN field 
use WRI. SEICTF does have a Formulary and some drug classes require prior approval before BCBS will approve the prescription under 
WRI. Charges filed manually, or through third party billing companies, will not be reimbursed. If you are unable to obtain approval or 
confirmation, please contact SEICTF at (800) 388-3406 for assistance. 

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SEICTF FORM 3-A REV 9/13/2017 

PLEASE SEE PAGE 2 OF FORM FOR CLAIMS FILING INSTRUCTION 

PAGE 1 OF 2