Treatment Authorization
We are authorizing the below listed U.S. HealthWorks(s) to provide treatment to our employees. By doing so, we acknowledge that if the claim is denied by our insurance carrier, we will notify USHW of the denial and will be responsible for payment for all services rendered and any medically-necessary items dispensed.
This authorization will be valid for up to 72 hours from time of submission. Please send employee into the clinic within the valid timeframe. If the employee presents to the clinic after the 72 hours has expired, additional authorization may be requested by U.S. HealthWorks.
* indicates required field
Medical Center Selection
* Select Medical Center State
* Select Medical Center
Employer Details
* Employer Name:
  Employer Number:
* Employer Contact Name:
* Address:
* City:
* State:
* Zip:
* Phone:
  Phone (after hours/cell):
  Fax:
* Email Address:
Employee Details
* Patient Name:
* Department:
* Does Employee Work For a Temp/Leasing Company:
  Temp Agency Name:
Insurance Details
  Insurance Company Name:
  Claims Address:
  City:
  State:
  Zip:
  Phone:
  Policy Number:
  Effective Date (MM/DD/YYYY):
  Expiration Date (MM/DD/YYYY):
Services Requested
At least one service is required to be checked
Date of Injury (MM/DD/YYYY):
  Last Work Date (MM/DD/YYYY):
  Injured Body Part:
  Claim Number:
Comment:
Exam Type:
  Protocol Number:
Type of Test
   
  DOT Agency (if applicable)
  Reason/Purpose
  Protocol Number or Comment:
  NOTE: Picture ID REQUIRED for Drug Testing
Services:
 
 
 
 
  Comment:
Authorized By
* Name:
* Title:
* Phone:
  Phone (after hours/cell):
  By checking this box I agree that I am authorized by the above employer to submit Treatment Authorizations to U.S. HealthWorks.