Authorization Form

As employers, you may submit this Authorization Form for treatment of your employees at your own convenience.  Once submitted, the form is sent  directly to our office authorizing the treatment of your injured employee. 

The Authorization Form may also be printed upon completion and the employee may bring it in at the time services are rendered, it can also be faxed directly to our office at: 786-923-4001, or we will simply call each employer to verify authorization upon arrival of the injured employee. 

                 Employer Authorization Form

Please fill out the entire top portion regarding pertinent information concerning your company, and check off all boxes that apply to the patients visit. Please electronically sign and date the bottom of the authorization form, otherwise we will simply call to verify authorization.

Example:

If your employee is coming in for an injury, check "work related injury", then check off whether you would like a drug screen performed at the time services are rendered. 

Please note: All forms submitted after 5:00pm EST will not be received until the following business day.
Although, all information completed online may be printed and faxed directly to our office or brought in at the time of rendered services.
Thank you for your understanding.