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This document is to authorize and refer an employee for evaluation and treatment related to work-related injuries or employment-related healthcare services.

How to fill out employers authorization and referral

How to fill out Employer’s Authorization and Referral for Occupational Health Services

1. Obtain the form: Download or request the Employer’s Authorization and Referral for Occupational Health Services form from your employer or relevant health services provider.
2. Fill in employer details: Enter the employer's name, address, phone number, and contact person.
3. Employee details: Provide the employee’s full name, job title, department, and any identification number if applicable.
4. Reason for referral: Clearly state the reason for the referral, such as medical evaluation, work-related injury, or health assessment.
5. Specify services needed: Indicate the specific occupational health services required (e.g., drug testing, medical exams).
6. Employee consent: Ensure that the employee has signed the consent section allowing the release of medical information.
7. Review and sign: Double-check all entered information for accuracy and completeness, then have an authorized representative sign the form.
8. Submit the form: Send the completed form to the occupational health services provider or as instructed.

Who needs Employer’s Authorization and Referral for Occupational Health Services?

1. Employees who are seeking medical evaluations related to work-related injuries or health assessments.
2. Employers who need to refer employees for occupational health services as part of workplace safety and health policies.
3. Organizations that require verification of an employee's fitness for duty before returning to work.

For pdfFiller’s FAQs

What is Employer’s Authorization and Referral for Occupational Health Services?

Employer’s Authorization and Referral for Occupational Health Services is a document that employers use to authorize an employee to receive specific occupational health services, typically related to work-related injuries or health assessments.

Who is required to file Employer’s Authorization and Referral for Occupational Health Services?

Employers who seek to provide their employees with occupational health services, particularly in cases of work-related injuries or medical evaluations, are required to file this form.

How to fill out Employer’s Authorization and Referral for Occupational Health Services?

To fill out the form, the employer must provide essential information including the employee's details, the nature of the referral, the specific services authorized, and any relevant medical history or incident details.

What is the purpose of Employer’s Authorization and Referral for Occupational Health Services?

The purpose of the Employer’s Authorization and Referral is to ensure that employees receive necessary health services promptly while also protecting the employer’s interests in managing healthcare costs and liabilities related to workplace injuries.

What information must be reported on Employer’s Authorization and Referral for Occupational Health Services?

The information that must be reported includes the employee's name, job title, description of injury or condition, recommended services, and any specific instructions or additional information deemed necessary for the healthcare provider.