Occupational Health Authorization & New Business Form

Company Name

Employee Name

Authorizing Contact

Authorizing Contact Email

Date

Time

Services Required

Does this employee require injury treatment? Does this employee require injury treatment? Yes No

WC Payor - Please provide your WC info if you would prefer that we bill your insurance. If your company would like to be billed directly, please input BILL DIRECT. - Please provide your WC info if you would prefer that we bill your insurance. If your company would like to be billed directly, please input BILL DIRECT.