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6900 E. 47th Avenue Drive, Suite 100, Denver, CO 80216
Call Us: (303) 333-4411
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Treatment Authorization Form
Date
(Required)
MM slash DD slash YYYY
Company
(Required)
Employee Name
(Required)
Supervisor Name
(Required)
Supervisor Phone
(Required)
Supervisor Email
(Required)
Check all that apply
Medical Treatment
On the Job Injury
Date of Injury
(Required)
MM slash DD slash YYYY
Time of Injury
Hours
:
Minutes
AM
PM
AM/PM
Claim Number
Type of Injury (describe complaint):
(Required)
Physical Examinations
DOT New Hire
DOT Re-Certification
Return to Work Evaluation
Respiratory Physical
Other/Specify Below
Specify
Breath Alcohol Test
DOT
Non-DOT
Drug Screens
DOT
Urine
Hair
Non-DOT Lab Based
Saliva
Non-DOT Urine STAT Test
Reason for Drug and/or Alcohol Testing
Pre-Employment
Post Accident
Random
Reasonable Suspicion
DOT Return-to-Duty
DOT Follow-Up
Additional Information:
Treatment Authorized By:
(Required)
