Employer Authorization for Treatment

Employer Authorization for Treatment
Company Name
We authorize Sand Canyon Urgent Care to provide medical treatment to the employee named below.

If the claim is denied by our insurance carrier, we will notify Sand Canyon Urgent Care and will be responsible for payment for all services rendered and any medically-necessary items dispensed.
Company Details

(Risk Manager, Human Resources Manager, Safety Manager, etc.)
Primary Contact Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date

MonthDayYear
Employee Details
Employee Name

First NameLast Name
Does the employee work for a temp or leasing agency?
Injury Information
Date of Injury

MonthDayYear
Please select a reason for your request
Does the employee need drug or alcohol screening(s)?
Authorization and Signature
Name: Type your full name below to acknowledge authorization.

First NameLast Name
Authorization
Should be Empty:

Company Details