Authorization Form

AUTHORIZATION FOR MEDICAL TREATMENT
We are authorizing the below listed Edinger Urgent Care to provide treatment to our employees. By doing so, we acknowledge that if the claim is denied by our insurance carrier, we will notify Edinger Urgent Care of the denial and will be responsible for payment for all services rendered and any medically-necessary items dispensed.
Edinger Urgent Care Edinger & Occupational Health

1530 East Edinger Ave., Suite 1 Santa Ana, California 92705

Phone: (714) 442-0600 |. Fax Number: (714) 542-0038

www.EdingerUrgentCare.com
COMPANY NAME
Primary Contact Name
Risk Manager, HR, Safety, etc.
Address Line 1
Address Line 2
CITY
STATE
ZIP
PHONE
After Hours Cell Phone
Please enter a valid phone number.
EMAIL
example@example.com
DEPARTMENT
EMPLOYEE NAME
DATE

MonthDayYear
Date
POSITION
Time

Hour Minutes

AM/PM Option
Authorized By:
DOES EMPLOYEE WORK FOR A TEMP/LEASING COMPANY?

YesNo
NAME OF TEMP AGENCY
PHONE
EMAIL
example@example.com
SIGNATURE

Clear
AFTER HRS / CELL PHONE
INSURANCE COMPANY NAME
CLAIMS ADDRESS
EFFECTIVE DATE

MonthDayYear
Date
POLICY #
EXPIRATION DATE

MonthDayYear
Date
INJURY INFO
DATE OF INJURY

MonthDayYear
Date
INJURED BODY PART(S)
CLAIM
If Available
Is this a Return To work (Fit for Duty) Evaluation?

Yes.N/A
Return to work / Fit for duty evaluation details
Is this a Post-offer Physical, or other Occupational Physical Evaluation?

YesN/A
Physical Exam Type (additional info)
DRUG/ALCOHOL TESTING? - If YES, select from options. If no, Skip.

DOT DRUG TESTDOT BREATH ALCOHOL TESTNON-DOT DRUG TESTNON-DOT BREATH ALCOHOL TESTINSTANT DRUG TEST
Reason / Purpose

Pre-employmentReasonable SuspicionReturn to DutyRandomPost-InjuryPost AccidentFollow-up
Verbal Authorization

Yes
Should be Empty:

AUTHORIZATION FOR MEDICAL TREATMENT

Edinger Urgent Care Edinger & Occupational Health

1530 East Edinger Ave., Suite 1 Santa Ana, California 92705

Phone: (714) 442-0600 |. Fax Number: (714) 542-0038

www.EdingerUrgentCare.com

INJURY INFO