Get Wellspan Occupational Health Employer Authorization Form 2021-2025

Filling out the WellSpan Occupational Health Employer Authorization Form online is a straightforward process that ensures proper documentation for workplace health services. This guide will provide you with clear, step-by-step instructions to complete the form accurately.

Follow the steps to fill out the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the employer's name and selecting if the employee is from a staffing agency. If so, specify the name of the agency.
3. Next, input the authorized person's name. Make sure to print the name clearly and provide a signature if required.
4. Fill in the employee's information including the full name, address, and social security number to ensure accurate identification.
5. Enter the employee's email address and date of birth in the specified fields.
6. Indicate the reason for the visit by checking all applicable options such as work-related injury, physical examination, or substance abuse testing.
7. If relevant, provide the date of occurrence for injuries and specify the body part affected.
8. For substance abuse testing, indicate the type of testing required and the reason for the test by selecting the appropriate options.
9. Fill out any additional procedures required such as PPD tests or physical examinations, choosing all that apply.
10. If applicable, check the billing options to indicate whether the employee will pay for charges related to the visit.
11. Finally, include any specific instructions or comments relevant to the visit before submitting the form.
12. Once completed, save the changes, and then choose to download, print, or share the form as necessary.

Start filling out your WellSpan Occupational Health Employer Authorization Form online today to ensure timely health services for your team.