Authorization Form for Treatment

Please note: All Authorization Forms submitted after 5pm EST Monday-Friday will not be recieved until the following business day including Saturdays, Sundays, and Holidays. Although, authorizations brought in at the time of service, faxed authorizations, or verbal authorizations are all accepted during regular business hours.

INSURANCE INFORMATION

Employee Name:

Employer Name:

Employer Address:

Contact Person:

Insurance Carrier:

Insurance Phone:

Insurance Address:

WORK COMP INJURY INFORMATION

Work Related injury:

Yes No

Light Duty available:

Yes No

Drug Screen required with injury:

Yes No (if yes, please check type below)

PHYSICAL INFORMATION

Pre-Placement Physical:

Yes No

DOT Physical:

Yes No

CBC:

Yes No

CMP/Smac:

Yes No

Pulmonary Function:

Yes No

PPD:

Yes No

EKG:

Yes No

Urine Drug Test:

Yes No
Blood Alcohol Breath Alcohol (BAT)

Chest X-ray:

Yes No

Hepatitis B Injection:

1st 2nd 3rd

Comments:

Authorized by: Date:

At FastCare, we take all appropriate precautions when it comes to protecting your individual health information. We are required by federal law to provide a Notice of Privacy Policy that describes how health information that we maintain about you may be used or disclosed. The notice describes each use and disclosure that we are permitted to make, and provides a description of your rights and our obligations under federal and state privacy laws.

Notice of Privacy Policy

By submitting your information, you are acknowledging you have read our Notice of Privacy Policy above.

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Fast Care LLC. 20601 E. Dixie Hwy Suite #340, Aventura, FL 33180 | Phone: 786-923-4000 | Fax: 786-923-4001 | Email: info@myfastcare.com