workers' compensation.

Workers' compensation authorization form

Fill out the form below to schedule your Work Comp new patient evaluation.

Submit Our Form

"*" indicates required fields

Patient Information

Address*
DOB*

Other Information

Upload documents such as prescription, authorization, or any other medical forms.
Drop files here or
Accepted file types: jpg, gif, png, pdf, heic, heif, jpeg, Max. file size: 10 MB, Max. files: 5.

    By submitting this form you acknowledge and accept our Privacy Policy & Terms of Service