BHP Injury Authorization

BHP Injury Authorization
Testing Location*
Date*

MonthDayYear
Date
Company*
Requested By:*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Jobsite Contact Name*
Jobsite Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Employee Name*

First NameLast Name
SS#
Employee DOB

MonthDayYear
Date
Date Of Injury

MonthDayYear
Date
Payment Form*

Works CompensationCompany Pay
This authorizes the above-named patient to be seen and treated by Business Health Partners for the injury or illness that occurred on the date listed above.

In the event that any after-hours fees are not fully covered by the insurance provider, the remaining balance will be billed to your company. Additionally, any charges not reimbursed in accordance with the Louisiana or Texas Workers' Compensation fee schedule will be the financial responsibility of your company.
Person to Contact for Further Treatment*
Contacts Number*
Please enter a valid phone number.Format: (000) 000-0000.
Contacts Email:*
email@email.com
Comments
Services*

Drug ScreensAlcohol TestingOther
Drug Testing*

Quick TestNON DOT UrineDOT UrineDISAHair TestOral FluidObserved
Quick Test*

51012
DISA Drug Screen*

UrineHairOralDOT
Alcohol Testing*

NON DOTDOTDISABreathSaliva
DOT Agency*

FMCSAPHMSAFTAFAAFRAUSCG
DISA Consortium*

NASAPDCCHADCCHTDCCOFOther
Signature
Should be Empty: