Get Intent To Treat Form - Ferris State University

Filling out the Intent To Treat Form is an essential step for employees at Ferris State University seeking medical treatment related to workplace injuries. This guide will provide you with step-by-step instructions to complete the form correctly and efficiently.

Follow the steps to fill out the Intent To Treat Form online.

1. Press the ‘Get Form’ button to acquire the Intent To Treat Form and open it for editing.
2. In the 'Employee’s Name' field, clearly print your full name as it appears in your employment records.
3. Fill in the date from which you intend to treat with a specific physician or hospital in the designated field.
4. In the field provided, write the name of the physician or hospital where you plan to seek treatment.
5. Enter the complete address of the physician or hospital, ensuring to include the city, state, and zip code.
6. Provide the phone and fax number of the physician or hospital to facilitate communication regarding your treatment.
7. Specify the body part that sustained the injury in the appropriate section, and include the date of injury in the specified field.
8. Read the authorization statement carefully, confirming that you are allowing the listed physician or hospital to share your medical information with Ferris State University.
9. Sign and date the form in the appropriate sections to validate your request for treatment.
10. Once you have completed the form, you can save your changes, download a copy, print it for your records, or share it as necessary.

Complete your Intent To Treat Form online today to ensure you receive timely medical care.