Get Wellspan Occupational Health Authorization Form - Wellspan

This guide provides a clear and supportive approach to completing the WellSpan Occupational Health Authorization Form online. By following these detailed steps, users can ensure their form is filled out accurately and efficiently.

Follow the steps to successfully fill out the authorization form.

1. Click ‘Get Form’ button to obtain the form and open it in the document editor.
2. Begin by indicating the location where you will receive services by checking the appropriate box beside the corresponding address.
3. Fill in the company name and phone number in the designated fields. Ensure that the information is accurate and legible.
4. Enter the employee's full name in the provided space. This section must be completed thoroughly.
5. Provide the employee's address in the designated section, ensuring that all details are correct.
6. Input the employee's Social Security number and date of birth in the appropriate fields.
7. Print the name of the authorized person in the designated area.
8. Sign the form in the signature section to validate the authorization. If providing an electronic signature, check the box indicating this option.
9. For injury-related treatments, provide the date and time of the injury in the designated area. Describe the injury thoroughly, including physical complaints and affected body parts.
10. Select the type of physical or procedures needed by checking the appropriate boxes. This includes options for drug and alcohol testing and various physical exams.
11. Complete any additional information or specifications in the 'Other' section if necessary.
12. Review the entire form for accuracy and completeness before finalizing your submission.
13. Once completed, save your changes, and then download, print, or share the form as needed.

Start completing your WellSpan Occupational Health Authorization Form online today!