Employer Authorization Form - Doctors Care

Employer Authorization Form

Complete this form and present at the time of service.

Date: Company: Company Address: Primary Contact:

Patient Name:

REQUIRED SERVICES (check all that apply)

Work Related

Worker's Compensation Injury Treatment:

Date of Injury: Type of Injury:

Post-accident Drug Screen required

Phone:

Fax: BT Account #:

Physical Examination

DOT Physical Pre-Employment PE Respiratory Clearance PE Physical (Other):

Specify:

Drug Screen/Breath Alcohol Testing

Drug Screen

DOT: (check agency below)

DOT Agency: FMCSA

FTA

FAA

FRA

Non-DOT: (fill in test code below)

5 Panel

9 Panel

7 Panel

Other

Instant

Breath Alcohol

DOT

Non-DOT

PHMSA USCG

10 Panel

Special Examination

Audiogram Chest X-ray Hepatitis B Profile PPD (TB test) Flu Shot Other: Other:

Blood Lead Level Hepatitis B Immunization Spirometry with Letter Tetanus

REQUIRED FOR ALL WORKER'S COMPENSATION CLAIMS:

Has Employer filled out First Report of Injury?

Yes

No

Where are claims to be filed?

Employer

W/C Carrier:

Phone:

Address:

BILLING COMPANY INFORMATION (OPTIONAL):

Billing Company:

Phone:

Address:

(send copy if available)

Carrier

Billing Company

Policy #:

Policy #:

This Certifies that the above information is correct. I authorize the medical provider to provide medical treatment to the employee named above.

Signature or Company Authorization Number

Date

Printed Name

Position Title

For Internal Use Only

Form Completed By

Initials

Center Name ? 2014 Doctors Care is a registered trademark of UCI Medical Affiliates, Inc.

Date

[OCC-F001-(02-14)]

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