Concentra Authorization Form – Fill Out and Use This PDF

Concentra Authorization Form can be filled out in our multi-purpose form builder; a drag and drop tool allows you to design forms from scratch with no coding required.

Click on the orange button down below to start our PDF tool. It will allow you to complete this form. Our versatile toolbar will let you access any PDF you require with any device anytime.

Get Form Now Download PDF

Concentra Authorization Form first page preview

Concentra Authorization Form PDF Details

We hope you enjoy this blog post about the importance of using a Concentra Authorization Form. We will discuss what a Concentra Authorization Form is, how they help with patient care and how they can improve your hospital's effectiveness. A Concentra Authorization Form is a document that helps medical professionals better organize their work for patients coming in to be admitted. It helps them create an organized schedule for all aspects of the patient's stay from surgery to discharge, as well as foresee any problems before they happen and take steps to prevent them from happening at all. This reduces overall costs by ensuring everything goes smoothly without any delays or changes necessary which would incur extra cost later on if not prevented now.

The listing features information regarding the Concentra Authorization Form. It might be helpful to learn its size, the average time required to fill out the form, the blanks you'll have to fill in, etc.

Question	Answer
Form Name	Concentra Authorization Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	20
Avg. time to fill out	4 min 15 sec
Other names	Concentra Employer Authorization Form, Concentra Authorization for Examination or Treatment Form

12

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

How to Edit Concentra Authorization Form Online for Free

We were building the PDF editor having the concept of making it as quick to apply as it can be. This is the reason the procedure of managing the concentra form pdf will likely to be simple use these particular steps:

Step 1: You can click the orange "Get Form Now" button at the top of this website page.

Step 2: At this point, you're on the file editing page. You may add information, edit current details, highlight certain words or phrases, put crosses or checks, add images, sign the file, erase unwanted fields, etc.

The PDF file you plan to prepare will consist of the following parts:

filling out concentra form part 1

Within the field cid, 84 Non, regulated drug screen, cid, 84 Rapid drug screen, cid, 84 Human Performance, cid, 43 cid, 84 Other, cid, 84 HA, ZM, AT cid, 84 Medical, Type of Substance Abuse Testing, cid, 84 Other, cid, 84 P, replacement cid, 84, Billing (check if applicable), cid, 84 Post, accident cid, 84 Random, cid, 84 Employee to pay charges, cid, 84 Follow, up and Special instructions, comments type in the information that the program asks you to do.

Filling in concentra form step 2

The application will require data to quickly prepare the box Please print, Phone:, Date, Con, cent, ra now offers urgent care, (Copies of this form are available, and © 2008 Con, cent, ra Inc.

step 3 to entering details in concentra form

Step 3: Once you choose the Done button, your ready form can be exported to all of your gadgets or to electronic mail chosen by you.

Step 4: Get a duplicate of every document. It may save you some time and make it easier to keep clear of troubles in the future. Also, your data isn't revealed or viewed by us.

Watch Concentra Authorization Form Video Instruction

Concentra Authorization Form isn’t the one you’re looking for?

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .