Workers Compensation
Employer Authorization Form

Please complete all data fields in the form below to streamline your request.

Patient Demographics

First Name

Last Name

Date of Birth

mm/dd/yyyy

Address

City

State

Zip Code

Cell or Work Phone #

Phone

Injury Information

Date of Injury

mm/dd/yyyy

Diagnosis

If you have a diagnosis and/or diagnosis code from employees initial assessment, please provide.

(i.e. cervical disk disorder, M50.0 (diagnoses code))

Body Part Approved for Treatment

(i.e. right foot)

Workers Comp Claim #

Translator Needed

*If a patient requires an interpreter, one must be provided.

Yes

Prior Surgery

Has the patient received any prior surgeries specific to this claim?

Yes

Prior Orthopedic Treatment

Has the patient received any orthopedic treatment specific to this claim?

Yes

Employer Information

Please provide the employers information at the time of injury

Employer Name

Address

Phone #

Phone

Insurance

Please provide employers insurance information.

Name of Insurance Company

Address

Phone #

Phone

Billing Address

Nurse Case Manager | Adjustor | Employer

Please provide contact information for the adjustor(s) assigned to the claim #.

Adjustor #1

Company Name

Adjustor Full Name

Phone #

Phone

Fax #

Phone

Adjustor #2

Company Name

Adjustor Full Name

Phone #

Phone

Fax #

Phone

Attorney

Has an attorney been assigned to your case?

Yes

Pre-Authorization

Is authorization required for the following services

Pharmaceuticals

Does OCPBC have authorization to dispense necessary pharmaceuticals?

Yes

MRI

Does OCPBC have authorization to perform necessary MRI?

Yes

DME

Does OCPBC have authorization to dispense necessary DME?

Yes

Please Upload the Necessary Documents

Please upload each document package separately.

First Report of Injury/Notice of Injury
Authorization of Treatment
Medical Records/Imaging Diagnostics

Drop your files here

Send me a copy of my responses

Report Abuse

Workers Compensation Employer Authorization Form

Patient Demographics

Injury Information

Employer Information

Insurance

Nurse Case Manager | Adjustor | Employer

Adjustor #1

Adjustor #2

Pre-Authorization

Workers Compensation
Employer Authorization Form