Paragon Systems/USMS

EMPLOYER’S AUTHORIZATION OF TREATMENT AND SERVICES FORM

Employee – must present government issued photo ID at time of service Employee/Applicant Name: Date of Birth:

Work Comp/Work Related Injury

Submit Claim for Payment To:

Employer Workers Comp Insurance or TPA

Occupational Health Services

Treatment of Work Related Injury

Pre-employment Non-DOT Physical Examination

EKG

Audiometry

CBC w/diff and Chemistry Profile + lipids

AUTHORIZED BY: We (Employer) are authorizing Inova Occupational Health/Urgent Care to provide work comp treatment and/or occupational health services to employees. By doing so, we acknowledge that we are responsible for payment of any and all services in the event a claim is not filed or denied. Signature of Person Authorizing Services:

Date:

Print Name of Person Authorizing Services:

OCCUPATIONAL HEALTH:

Inova Occupational Health – Alexandria

4700 King St, Suite 201

Alexandria, VA 22302

T 571-***-**** / 571-***-****

Mon – Fri - 8am – 4pm Appts Preferred

Kristina Morvay

Kristina Morvay