Medical Authorization Form

Name: Patient Plus
Price range: $

Electronically fill out the form below.

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Employee Name

Company Name

Company Contact Person

Social Security #

Job Site/Job Number

Injury Evaluation & Treatment Initial ExamFollow Up Exam

Insurance Carrier Information: *It is the responsibility of the company to call in a First Report of Injury (Form IA-1) to your worker's compensation insurance carrier.

Responsible Party Bill CompanyBill Insurance Carrier (Work Comp Policy)

Name

Phone

Claim #

Address

Adjuster

Physical Exam DOTNon-DOT w/ UAReturn-to-Work Exam

Reason Pre-EmploymentAnnualRe-CertificationOther

Breath Alcohol DOTNon-DOT

Reason Pre-Employment RandomPost-Accident Return-to-WorkReasonable Suspicion

Urine Drug Screen 5 Panel (QuickScreen)10 Panel (QuickScreen)12 Panel (QuickScreen)Non-DOT(Lab Performed)5 Panel (Lab Performed)10 Panel (Lab Performed)12 Panel (Lab Performed)DOTFMCSAPHMSAUSCGFTASynthetic MarijuanaSynthetic OpioidCustom Panel

Reason Pre-EmploymentRandomPost-AccidentReturn-to-WorkReasonable Suspicion

Observed YesNo

DISA BAT (Non-DOT)BAT (DOT)Urine (Non-DOT)Urine (DOT)PHMSAUSCGFMSCA

Reason Pre-EmploymentRandomPost-AccidentReturn-to-Work

Vision Testing Peripheral OnlySnellen

Other Testing COVID 19: PCRCOVID-19: Rapid AntigenPulmonary Function TestAccucheckEKGTB Skin Test

X-Rays X-Ray

Injury Location (Body Part)

Other Tests / Employer Notes

How would you like your results delivered? Employer PortalEmailFax

Email Address

Fax Number

Authorized Signature

Phone

* Required Field

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Medical Authorization Form

Services

Employers

Contact Us

Blog

Locations