Patient Authorization Form

Please take a moment to complete the following form with as much information as possible to assist our team with assuring a seamless process.

Patient information:

 

First Name:

Last Name:

Employer:

Contact Name:

 

Street Address:

City:

State:

Zip:

Phone:

Fax:

E-mail:

 

About Your Inquiry:

 

New Injury:

Date Of Injury:

Type Of Injury:

 

Payer/Carrier Information:

 

Payer/Carrier:

Claim Number:

 

Street Address:

City:

State:

Zip:

Phone:

Fax:

 

Description Of Services:

 

Drug Screen Required:

Drug Screen Type:

Reason:

DOT Testing Agency:

Alcohol Test:

Test Type:

Alcohol Source:

Physical:

If other Physical was selected, please explain:

Vaccinations:

If other Vaccination was selected, please explain:

Other Services:

 

Locations:

 

 4714 Okeechobee Blvd, West Palm Beach, FL 33463 M-F 7:30-7 Sat & Sun 9-5 640 21st Street, Vero Beach, FL 32960 M-F 9-7 Sat 9-5 Sun 11-5

 

Authorization:

 

Authorizing Person:

Phone:

Date Authorization Expires: (Required for Drug Screens):

 

I testify that the information in this form is accurate, and I authorize Coach Comp America to treat patient as requested above. (Enter your full name to "sign.")

 

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