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


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