Concentra Authorization Form PDF Details

At the heart of workplace health and wellness initiatives lies the Concentra Authorization form, an essential document that bridges the gap between employers, employees, and healthcare providers. This comprehensive form serves multiple purposes, from authorizing examinations or treatments to specifying the type of medical screenings – be it for work-related injuries, illnesses, or routine checks like drug screenings and physical examinations. It meticulously collects patient information, including their name, social security number, employer details, and even specifies billing responsibilities. Interestingly, the form also delves into specialized examinations such as asbestos screening, audiograms, and human performance evaluations, underlining its adaptability to various occupational health requirements. With an emphasis on ensuring that patients present a photo ID at the time of service, it underscores the importance of authentication and privacy. Special instructions or comments sections further customize the healthcare experience, ensuring that both patient and provider needs are clearly communicated and understood. The form’s role in facilitating efficient and effective healthcare service delivery within occupational settings cannot be overstated, making it a critical tool in maintaining a healthy workforce. Additionally, the document mentions Concentra's expansion into urgent care services for non-work related illnesses and injuries, indicating a broadening scope of care that accommodates a wide range of patient needs while also accepting numerous insurance plans. This aspect highlights the evolving nature of healthcare services in responding to the diverse requirements of today's workforce and the general public.

QuestionAnswer
Form NameConcentra Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesConcentra Employer Authorization Form, Concentra Authorization for Examination or Treatment Form

Form Preview Example

(Patient Must Present Photo ID at Time of Service)

Authorization for Examination or Treatment

Patient Name: ___________________________________________________

Social Security Number:___________________________________________

Employer: ___________________________________

Date of Birth: __________________________________________________

Street Address:___________________________________

Location Number: ___________________________________

Temporary Staffing Agency: ___________________________________

Work Related

 

Physical Examination

 

T Injury T Illness

T Preplacement

T Baseline

TAnnual T Exit

Date of Injury ___________________________________

DOT Physical Examination

 

Substance Abuse Testing+ (check all that apply)

T Preplacement

T Recertification

T Regulated drug screen T Breath alcohol

Special Examination

 

T Collection only

T Hair collect

TAsbestos

T Respirator

TAudiogram

T Non-regulated drug screen T Rapid drug screen

T Human Performance Evaluation+

T Other _________________

T HAZMAT

T Medical Surveillance

Type of Substance Abuse Testing

T Other _________________

T Preplacement

T Reasonable cause

Billing (check if applicable)

 

T Post-accident

T Random

T Employee to pay charges

 

T Follow-up

 

 

 

 

 

Special instructions/comments: _______________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

Authorized by: ______________________________________________________

Please print

Phone: ( ___________________________________________________ ) ______________________________________________________________

+Due to the nature of these specific services, only the patient and staff are allowed in the testing/treatment area. Please alert your employee so that they can make arrangements for children or others that might otherwise be accompanying them to the medical center.

Title: ___________________________________________________________

______________________________________________________

Date

Concentra now offers urgent care services for non-work related illness and injury. We accept many insurance plans.

(Copies of this form are available at www.concentra.com)

© 2008 Concentra Inc. All Rights Reserved. 06/08

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Within the field cid Nonregulated drug screen, cid Rapid drug screen, cid Human Performance Evaluation, cid, cid Other, cid HAZMAT cid Medical Surveillance, Type of Substance Abuse Testing, cid Other, cid Preplacement cid Reasonable, Billing check if applicable, cid Postaccident, cid Random, cid Employee to pay charges, cid Followup, and Special instructionscomments type in the information that the program asks you to do.

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