Authorization Form

"*" indicates required fields

MM slash DD slash YYYY
Employee Name*
Company Address*

Work Comp Injury

Choose below:

Insurance Carrier Information

It is the responsibility of the company to call in a First Report of Injury (Form 1007) to your workers compensation insurance carrier. Please provide carrier info and claim number below:
Please provide the claim number issued for this Workers Compensation Claim. Your assistance in providing the claim number for this injury will expedite the management of this injury and the processing of claims.

Services Rendered on Checked Items Only

Urine Drug Screen
Alcohol Testing
Hair Sample Drug Screen
*All DOT Drug Screens Must Specify Testing Agency
Reason for Test
Physical Exams
Laboratory Test
Authorized By