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JOB RELATED INJURY AUTHORIZATION FORM *EMPLOYER: Please complete this PRIORITY PASS and send it with the employee when they visit one of our DESERT VALLEY MEDICAL GROUP locations. *THIS PASS ID TO
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How to fill out job related injury authorization

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How to fill out job related injury authorization

01
Obtain the job related injury authorization form from your employer or human resources department.
02
Read the instructions and form carefully to understand the information required to complete the authorization.
03
Fill out your personal details, including your full name, contact information, and employee identification number.
04
Provide a detailed description of the job-related injury or accident, including the date, time, location, and circumstances.
05
Attach any relevant documentation, such as medical reports, witness statements, or incident reports.
06
Review the completed authorization form to ensure all information is accurate and complete.
07
Sign the form and date it.
08
Submit the filled out job related injury authorization form to the appropriate person or department designated by your employer.
09
Keep a copy of the completed form for your records.

Who needs job related injury authorization?

01
Employees who have suffered a job-related injury or accident and wish to seek compensation or benefits related to the injury.
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Job related injury authorization is a document that allows an employee to seek medical treatment for an injury sustained while on the job.
Employers are required to file job related injury authorization on behalf of their employees.
To fill out a job related injury authorization, employers must provide details of the injury, the employee's information, and the treatment being sought.
The purpose of job related injury authorization is to ensure that employees receive appropriate medical treatment for work-related injuries.
Job related injury authorization must include details of the injury, the employee's information, and the treatment being sought.
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