treatment-authorization-form

Employer Treatment Authorization Form

Employers may use this form to authorize occupational health, workers' compensation injury care, drug and alcohol testing, physicals, return-to-work evaluations, and related employer medical services at UrgentMed.

UrgentMed serves employers throughout Davie, Plantation, Broward County, and surrounding South Florida communities including Weston, Sunrise, Fort Lauderdale, Cooper City, Southwest Ranches, and Pembroke Pines.

Company / Employer Name * Employer name is required.

DBA or Parent Company (if any)

Company Main Phone

Company Email

Billing Address

City

State

ZIP

HR / Safety Contact * Contact name is required.

Title

Direct Phone * Phone is required.

Email * Email is required.

Bill This Visit To

Workers' Compensation Carrier Employer Employee Self-Pay TPA / Network (specify below)

Third-Party Admin / Network

Network Auth # / Reference #

Billing Notes

Patient Legal Name (Last, First, MI) * Patient name is required.

Date of Birth * Date of birth is required.

Last 4 SSN / Employee ID

Patient Phone

Patient Email

Preferred Language

Job Title

Department

Supervisor Name

Supervisor Phone

What UrgentMed is being asked to evaluate and provide.

Full duty release Modified / light duty No work / off work Return-to-work (RTW) evaluation Maximum medical improvement (MMI) Permanent impairment rating Functional capacity evaluation (FCE) Ref to spec / imaging if indicated

Authorized Rep. (Printed) * Authorized representative name is required.

Title

Direct Phone

Email

Signature *

Signature is required.

Date * Date is required.

Time

Send a copy of this authorization to the HR/Safety contact email above