Follow the steps to complete your form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred editing tool.
2. Enter the patient name in the designated field. Ensure that the name matches the identification presented.
3. Fill in the Social Security Number (SSN) of the patient in the appropriate field. This information is crucial for identification purposes.
4. Provide the company name associated with the patient. This identifies the employer taking responsibility for the examination or treatment.
5. Input the date of birth for the patient, ensuring it is accurate to avoid any confusion during processing.
6. Specify the location by providing the street address or location number where the service will take place.
7. Indicate the date of the injury if applicable, which is essential for work-related injuries or illnesses.
8. If applicable, include the name of the temporary staffing agency, as this may be required for employees sourced through agencies.
9. Select the relevant treatment category; options include work-related injury or illness, DOT physical, and various testing types. Make sure to choose all that apply.
10. Complete the job title field to specify the position related to the examination or treatment.
11. Select any special physical examinations required, based on the nature of the job or injury. This may include tests such as audiograms or drug screens.
12. Under the billing section, determine how the service will be paid. Provide details such as workers' compensation or insurance company information if applicable.
13. Lastly, ensure to fill in the authorized by section, including title, phone number, and date for proper authorization.
14. Once completed, review all entries for accuracy. You can then save changes, download the form, print it, or share with necessary parties.

Start filling out your Concentra Employer's Authorization for Examination or Treatment online today!