Authorization Form

  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Work Comp Injury

  • Insurance Carrier Information

    It is the responsibility of the company to call in a First Report of Injury (Form IA-1) 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