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Get Concentra Employer Authorization Form 2008

Auth Pad FT CUC. pdf 3/18/09 9 56 47 AM Patient Must Present Photo ID at Time of Service Authorization for Examination or Treatment Patient Name Social Security Number Employer Date of Birth Street Address Location Number Temporary Staffing Agency Work Related Injury Physical Examination Illness Preplacement Baseline Annual Exit Date of Injury DOT Physical Examination Substance Abuse Testing check all that apply Regulated drug screen Collection only Breath alcohol Hair collect Non-regulated drug screen Special Examination Asbestos Rapid drug screen Other Type of Substance Abuse Testing Respirator Audiogram Human Performance Evaluation HAZMAT Medical Surveillance Billing check if applicable Reasonable cause Post-accident Recertification Random Employee to pay charges Follow-up Special instructions/comments Due to the nature of these specific services only the patient and staff are allowed in the testing/treatment area. Please alert your employee so that they can make arrangements for children or others that might otherwise be accompanying them to the medical center. Authorized by Title Please print Phone Date Concentra now offers urgent care services for non-work related illness and injury. Auth Pad FT CUC. pdf 3/18/09 9 56 47 AM Patient Must Present Photo ID at Time of Service Authorization for Examination or Treatment Patient Name Social Security Number Employer Date of Birth Street Address Location Number Temporary Staffing Agency Work Related Injury Physical Examination Illness Preplacement Baseline Annual Exit Date of Injury DOT Physical Examination Substance Abuse Testing check all that apply Regulated drug screen Collection only Breath alcohol Hair collect Non-regulated drug screen Special Examination Asbestos Rapid drug screen Other Type of Substance Abuse Testing Respirator Audiogram Human Performance Evaluation HAZMAT Medical Surveillance Billing check if applicable Reasonable cause Post-accident Recertification Random Employee to pay charges Follow-up Special instructions/comments Due to the nature of these specific services only the patient and staff are allowed in the testing/treatment area* Please alert your employee so that they can make arrangements for children or others that might otherwise be accompanying them to the medical center. Authorized by Title Please print Phone Date Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans. Copies of this form are available at www. concentra*com 2008 Concentra Inc* All Rights Reserved* 06/08. Authorized by Title Please print Phone Date Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans. Copies of this form are available at www. concentra*com 2008 Concentra Inc* All Rights Reserved* 06/08. .

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