Fillable ICW Group - MPN Medical Authorization Form for California

Medical Authorization Form This form should be completed by the employer and given to the injured worker to take to the clinic for the first visit. Note: If the worker has pre-designated a treating physician, this form must still be taken and the employer should call ahead to notify the doctor's office. Employer: complete for worker's first visit Injury Information Worker's name: Date of injury: Details: (ex. 12/20/2011) Company Information Company name: Address: Policy number: (ex. WSD-1234567) Referral Information Referrer's name: Title: Phone: Date of referral: (ex More

Medical Authorization Form. This form should be completed by the employer and given to the injured worker to take to the clinic Less