Get Employer Authorization - Stjohnprovidence

Filling out the Employer Authorization for Treatment/Billing is essential for ensuring that employees receive the necessary care and services. This guide will provide you with a clear, step-by-step process for completing the form online, making it easy for users at all levels of experience to navigate.

Follow the steps to successfully complete the Employer Authorization form.

1. Click the ‘Get Form’ button to obtain the Employer Authorization - Stjohnprovidence form and open it for editing.
2. Fill in the date provided at the top of the form, followed by the employee's name. Ensure the information is accurate to avoid any issues.
3. Enter the job title and duties of the employee in the designated section. This helps establish the context of the services requested.
4. Provide the employer's name and contact phone number. This ensures that the healthcare provider can reach out if necessary.
5. Complete the employer's address, including the street, city, state, and zip code. This information is crucial for processing the authorization correctly.
6. Indicate the services authorized for the employee by checking all applicable boxes in the services section. Be specific about injury care or other required tests.
7. If there is an injury, fill in the date and time of the injury occurrence. This information supports the medical assessment and follow-up care.
8. Specify whether a controlled substance test is required by checking the appropriate box. If yes, indicate which type of tests are needed.
9. For any physical exams or other health screenings required, check the relevant boxes and provide any specifics requested.
10. In the 'Other Services Requested' section, include any additional services that may be necessary for the employee.
11. Print the name of the authorized individual and provide their signature in the designated fields to finalize the authorization.
12. After completing all sections, review the form for accuracy and completeness. Once confirmed, save your changes, and download or print the document as needed.

Complete your documents online for a seamless submission process.