Treatment Authorization Form
Complete this form to authorize treatment and services for an employee.
Employee Information
Employee Name
*
Employee Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Email Address
example@example.com
Employee ID #
Job Title
Employer Information
Employer Name
*
Employer Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Employer Address
*
Employer Email Address
example@example.com
Authorized Services
Service(s) Authorized
*
Pre-employment Physical
DOT/DMV Physical
DOT Drug Screen
DOT BAT Screen
Rapid Drug Screen
Non DOT Drug Screen
Non DOT BAT Screen
TB Skin Test
TB Questionnaire
Audiogram
Pulmonary Function Test
Respirator Clearance
Fit Testing
OSHA Questionnaire
Other
Authorization Details
Date
-
Month
-
Day
Year
Date
Authorized Employer Contact Name
Authorized Employer Contact Signature
Submit Authorization
Submit Authorization
Should be Empty: