Workers' Compensation Medical Treatment Authorization Form

							                                                                                                                                                                          Print Form
                                                             Workers' Compensation Medical Treatment Authorization Form
                                                                                               ( INJURY )                        ** All services require photo
                                                                                                                                 identification to be provided
                                                             DIRECTIONS:                                                        by employee at time of service.
                                                               Complete all Sections A - D entirely


This is authorization to provide medical services to:___________________________________________ DOB_____________ SS# __________________
                                                                                  ( Print Patient Name Above)

   Section A:          Employer Information                            Section B:          Patient Injury Information   Additional Comments/ Notes:
Employer Name:                                                Injured Body Part(s):


Address:
                                                              Date of Injury:

Phone #
                                                                         Section C:       Urine Drug/Alcohol Tests
Fax #                                                            Urine Drug Screens
                                                                        Collection Only
                                                                                      y
Is Alternative Work available?         Yes         No            Florida Drug Free Workplace
                  Insurance Carrier                                     5 Panel HRS
Name:                                                                   8 Panel HRS
Address:                                                                10 Panel HRS
                                                                 DOT
                                                                         DOT / NIDA
Claim #
If not available has claim been reported     Yes        No                              Alcohol Testing
Adjuster Name:                                                                  Lake Ella , Appleyard , North & Mahan
                                                                                             Locations Only
                                                                       Non – DOT Breath Alcohol Test
Fax #                                                                  DOT Breath Alcohol Test
Phone #
  Section D: Authorization Information
Print Name of Authorizer:                                    Authorizer Signature:                                      Phone #


                                                             Title:                                                     Date:

Fax or Mail results to:                                      Billing Address:                                           For Patients First Use Only: Phone Auth received by:


                                                                                                                        Date & Time