EMPLOYER’S TREATMENT AUTHORIZATION FORM

EMPLOYER’S TREATMENT AUTHORIZATION FORM
EMPLOYEE INFORMATION
Valid identification is needed for all drug screens. Employees must be present to the clinic 3 hours prior to closing.
Employee Name*
Date*

MonthDayYear
Date
ILLNESS OR INJURY INFORMATION
Date and Time When Occurred*

MonthDayYear
Date
Location*
Brief Description of Illness/Accident*
Name of Whom We Should Contact*
Their Email Address*
Please select the service that you would like the employee to receive:
Physical

DOT Drug TestInstant Drug TestWhisper Hearing TestDOT PhysicalRegular or Executive PhysicalWorker’s Compensation Injury/IllnessDrug screen required for NEW injuries
EMPLOYER INFORMATION AND AUTHORIZATION
Company Name*
Supervisor Name*
Contact Person*
Contact Phone Number*
Work Phone*
Work Fax*
AUTHORIZATION: Southern Immediate Care is authorized to treat the above named employees and to bill for services rendered.
Signature*

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Date*

MonthDayYear
Date
****EMPLOYERS: Please submit this form for each employee for every encounter. ***
***All follow-up visits should be directed to Alabama Comp.****
***For internal use only***
Should be Empty: