Authorization form • Peachtree Immediate Care

URL

This field is for validation purposes and should be left unchanged.

Patient/Employee Name*

First Last

Company Name*

Branch

Please select the type of visit:*

Drug Screen
Exam
Workplace (Worker’s comp) Injury
Other

Workplace Injury

Type of visit

New Injury
Follow-up

Date of Injury

Area of body where injury is:

Can medication be dispensed?

Yes
OTC only
No

Carrier Information

Billing Type

Employer Paid
Insurance Carrier/TPA

Workers Comp Carrier Name

Claim #

Social Security Number

Carrier Address

Street Address Address Line 2 City State ZIP Code

Examination

PHYSICAL EXAMINATION

Pre-employment
Fit For Duty
Annual
Respiratory Clearance
DOT
RTW
Silica/Asbestos
OSHA Questionnaire
Other

OTHER SERVICES

Screening

SUBSTANCE ABUSE TESTING

REASON FOR SUBSTANCE ABUSE TESTING

Pre-employment
Random
Reasonable Suspicion
Return to Duty (RTD)
Post-Accident
Follow Up

Location

At which location are they going to be seen?*

Authorization

Your name*

First Last

Title*

Date*

I authorize this request*

Yes

Phone Number*

Email*

HR Safety Manager

Comments

CAPTCHA