workers' compensation.

Workers' compensation authorization form

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

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Patient Information

First Name*

Last Name*

Address*

Street Address City State ZIP Code

Home/Cell*

Email (Optional)

DOB*

Employer*

Body Part*

Service Type*

Authorization Visits and Date Range (Optional)

Other Information

Case Manager/Adjuster Name*

Case Manager/Adjuster Phone*

Case Manager/Adjuster Fax*

Case Manager/Adjuster Email*

Upload Documents

Upload documents such as prescription, authorization, or any other medical forms.

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Accepted file types: jpg, gif, png, pdf, heic, heif, jpeg, Max. file size: 10 MB, Max. files: 5.

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