Payment Authorization {LIBC-215} | Pdf Fpdf Docx | Pennsylvania

 Pennsylvania   Workers Comp 
Payment Authorization {LIBC-215} | Pdf Fpdf Docx | Pennsylvania

Last updated: 2/6/2025

Payment Authorization {LIBC-215}

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Description

LIBC-215 - PAYMENT AUTHORIZATION FORM. This form is to be completed by the Person Entitled to Compensation. The form is used to request to begin direct deposit, change deposit accounts, or discontinue direct deposit/elect payment by paper check. This form must be completed and submitted to the insurance carrier/self-insured employer. www.FormsWorkflow.com

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