WORKERS’ COMPENSATION AUTHORIZATION

Patient Name *
Patient DOB *
Date of Injury *
Body Part to be Checked *
Claim # *
Contact Person/Adjuster *
Insurance Carrier *
Employer *
Mailing Address *
City *
State *
Zip *
Phone # *
Fax #
I am authorizing treatment and /or payment for the above workers compensation employee. * I Agree
Authorized Name *
Company *
Date *