Employer Authorization | Occupational Care Services

By signing this authorization, the said employer acknowledges full responsibility for payment for ALL services related to examinations, screening, diagnostic testing and treatment and or medications deemed necessary by the treating Physician for the authorized individual named in this form unless it is previously requested to collect payment at time of service from the individual. It is understood that services will be paid in full upon receipt of billing for all amounts due. It is also understood that the employer will be responsible for payment of all services related to injury or illness care of the employee if said case is determined work related or not, or if the claim is denied by the workers' compensation insurance carrier.

Employer Authorization Form

Authorization for Occupational Health Services

ALL services included in account profile for respective services WILL be performed unless otherwise stated.