Mail the form and other documents to: PennDOT Risk Management Office P.O. Box 69005. Harrisburg, PA 17106-9005.By signing this form, you allow us to share your protected health information (PHI) with the persons and organizations you put on this form. My dad's license is expiring soon. He no longer drives and is home bound. Instructions: Fill out all applicable sections on all pages completely and legibly. START HERE: Employers must ensure the form instructions are available to employees when completing this form. When this application is processed, the previous title will become void. See What is backup withholding, later. For providers not enrolled with OHP, complete and submit the OHP 3113 form to OHP Provider Enrollment.

Authorization Letter With Attached Id In Pennsylvania

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