Workers Compensation Employer Authorization Form

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*

Address*

City*

State*

Select

Zip Code*

Cell or Work Phone #*

Phone

Injury Information

Date of Injury*

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

Facility Name*

Address

Phone #*

Phone

Full Name of Treating Physician*

Prior Orthopedic Treatment*

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

Yes

Facility Name*

Address

Phone #*

Phone

Full Name of Treating Physician*

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*

Email*

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

Attorney Information

If an attorney has been assigned to your claim, please provide their informaiton.

Name of Law Firm*

Phone #*

Phone

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

Drag and drop files here or

Send me a copy of my responses

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