Get Employer Authorization - Med Express

This guide provides detailed instructions on how to complete the Employer Authorization - Med Express form online. By following these steps, you can ensure that the form is filled out accurately and efficiently to facilitate your employee’s visit.

Follow the steps to complete the form effectively.

1. Press the ‘Get Form’ button to access the Employer Authorization - Med Express form and open it in your preferred editor.
2. Fill in the employee name, ensuring it is clear and legible.
3. Input the employee’s Social Security Number (SSN) in the designated field.
4. Provide the company name where the employee works.
5. Complete the company address by filling in the street address, city, state, and zip code.
6. Enter the name of the Designated Employer Representative (DER).
7. Fill in the DER's phone number in the specified format.
8. Indicate if there is an existing account at the Med Express location by selecting 'Yes' or 'No'.
9. If you would like to set up an account, indicate that by selecting 'Yes' or 'No'.
10. Select the type of services required, such as workers compensation or urine drug screens, by checking the appropriate boxes.
11. For each type of testing or service needed, specify any further details or check additional relevant boxes.
12. Fill out any necessary ancillary services, such as lab tests or physical examinations, by checking the respective boxes.
13. If applicable, provide information for the MRO (Medical Review Officer) by entering their name, address, phone, and fax number.
14. Sign the authorization by the supervisor or DER, and include the date.
15. Fill in contact information for phone, fax, and email if required.
16. Choose how you would like results relayed by indicating either fax or email.
17. Save changes, and then download, print, or share the completed form as needed.

Complete the necessary documents online to streamline your process.