Work Injury Authorization & Employer Consent Form

Work Injury Authorization & Employer Consent Form

This form must be completed by the employer or an authorized company representative before OneSpotMD Urgent Care evaluates or treats an employee for a work-related injury or illness. By submitting this form, you authorize OneSpotMD Primary & Urgent Care PLLC to evaluate and treat the employee named below for a work-related injury or illness, and you acknowledge responsibility for payment through your workers’ compensation carrier or directly from the employer as applicable. For assistance, contact OneSpotMD Urgent Care — Steele Creek (980-880-5588) or OneSpotMD - Plaza Midwood (704-731-8656).
Employer Information

Name, title, and contact method of the person who should receive work status notes, test results, or medical updates (e.g., HR, Safety Officer, Nurse Case Manager).
Company name
Use legal business name “ABC Manufacturing, Inc.”
Authorized Representative Name
Title
Safety / HR / Manager / Owner
Phone Number
Email Address
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is this same person also the contact for work status updates and medical results?

YesNo
Work Status & Results Contact (if different from above)
Name
Title
Safety / HR / Manager / Owner
Phone Number
Please enter the direct number if possible
Email
For employer portal invite or secure emails for work status updates
How should we send the work status updates?

FaxEmployer PortalSecure Email
Post-Accident Testing Authorization (Employer-Paid)

Please indicate whether your company requires any drug and/or alcohol testing to be performed for this employee’s post-accident or injury evaluation.Note: Workers’ Compensation insurance does not cover the cost of these tests. All testing performed under this section will be billed directly to the employer.Prices listed below are all-inclusive and cover specimen collection, laboratory analysis, and Medical Review Officer (MRO) services for applicable tests.Results will be released only to the employer or its authorized representative in accordance with company policy and applicable federal and state regulations.
Does your company require any drug testing or breath alcohol testing for this incident?

YesNo
Please select the test(s) that are required:

Urine Drug TestBreath Alcohol Test (BAT)
Urine Drug Test (Includes collection, lab, and MRO services)

Rapid Drug Test – 10-Panel (instant results) — $75DOT Drug Test (lab send-out) — $75Non-DOT Drug Test (lab send-out) — $75
Breath Alcohol Test (BAT)

DOT Breath Alcohol TestNon-DOT Breath Alcohol Test
Billing Details
How would you like this visit to be billed?

Workers’ Compensation InsuranceBill Employer Directly (Not Using Workers’ Comp)
Workers’ Compensation Insurance
Please provide the basic information below so OneSpotMD Urgent Care can bill your company’s Workers’ Compensation insurance carrier for this visit.

If your company has already filed the claim, please include the carrier name and claim number below.

If the claim has not yet been filed, we can proceed with care today, and your company may contact our billing department once the claim number is assigned.

Once a claim number is available, please reach out to us at (980) 880-5588 or info@onespotmd.com so we can update your file and submit billing directly to the carrier.
Workers’ Compensation Insurance Carrier
Claim Number (if available)
Billing Address for Workers' Comp Carrier (If available)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Bill Employer Directly (Not Using Workers’ Comp)
Self-Pay Visit and Pricing Information

The standard fee for a work-related injury evaluation is $140, which covers the initial medical assessment by our provider.

If additional diagnostic testing or treatment is needed — such as X-rays, splinting, laceration repair, injections, or medications — these services will be billed separately.

Any additional costs will be reviewed with the patient before services are performed and will be collected at checkout after the visit.

For employers not yet set up in our billing system, payment for this visit will be collected by credit card over the phoneat the time of service.
Temporary Payment Contact (for Employer-Paid Visits)
Authorized Payment Contact Name
Phone Number
Please enter a valid phone number.
Should be Empty:

Work Injury Authorization & Employer Consent Form

Employer Information

Work Status & Results Contact (if different from above)

Post-Accident Testing Authorization (Employer-Paid)

Billing Details

Workers’ Compensation Insurance

Bill Employer Directly (Not Using Workers’ Comp)

Temporary Payment Contact (for Employer-Paid Visits)