Follow the steps to complete the form effectively

1. Click ‘Get Form’ button to access the form and load it in the editor.
2. Begin by entering the employee's name and date of birth in the designated fields. This ensures the correct identification of the individual being authorized.
3. Fill in the employee's address, including city, state, and zip code. Provide a valid phone number for direct communication.
4. Input the last four digits of the employee's social security number for secure identification.
5. Indicate the scheduled date(s) and time for the treatment, allowing ample time for processing and coordination.
6. Provide the company name and address, ensuring all information is accurate to avoid any administrative issues.
7. In the section labeled 'Treatment Authorized by', print your name and title. Sign the document to validate authorization and provide your phone number for follow-up inquiries.
8. Complete the 'Employer Information' section by designating a company contact person for results and/or physician calls, and selecting preferred communication methods (check all that apply).
9. If applicable, enter billing information, including the address if different from that of the employer contact.
10. Fill out details pertaining to the insurance policy, including the policy number, effective dates, carrier name, and claim number.
11. Indicate the details regarding the date of injury, injured body part, and other relevant information for workers' compensation.
12. Select the services required by checking the appropriate boxes, specifying drug/alcohol testing options and reason for the testing.
13. For OccMed services, enter the package name and ID required for the service.
14. Review the completed form for accuracy, ensuring all sections are filled out correctly.
15. Once satisfied with the information provided, save your changes, then download, print, or share the form as needed.

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