Employer Notification for Treatment Form

Authorizing the initial medical appointment

If you are injured on the job, you must submit the Employer Notification for Treatment form.

Electronic notification for the Bloomington and Indianapolis campuses

To access use your IU Network ID user name and passphrase:

All other campuses

Download and print the Notification for Treatment form

Medical provider by campus:

IU Columbus
Columbus Regional Occupational Health Physicians at 237 Washington Street, Columbus, IN 47201

IU East
Reid Hospital Occupational Medicine at 1100 Reid Parkway, Richmond, IN 47374

IU Fort Wayne
Parkview Occupational Health at 3415 Hobson Rd., Fort Wayne, IN 46085

IU Kokomo
WellNow Urgent Care at 1010 S Reed Road, Kokomo, IN, 46901

IU Northwest
Concentra Urgent Care at 7501 15th Avenue, Gary, IN 46406

IU South Bend
Concentra Urgent Care at 19567 Cleveland Road, South Bend, IN 46637

IU Southeast
Concentra Urgent Care at 901 West Broadway, Louisville, KY 40203