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VISALIA 4014 Carter St Visalia, LA 71373 Phone: (318) 4141800 Fax: (318) 4145555AUTHORIZATION FORM Send the form with your employee or fax it to: (318) 4145555DATE: ___EMPLOYEE NAME: ___ DATE OF INJURY:

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Trinity Medical Vidalia Clinicla is a medical facility located in Vidalia, providing healthcare services to the community.

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Providers can fill out Trinity Medical Vidalia Clinicla by including required information such as patient details, treatment provided, and any medications prescribed.

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The purpose of Trinity Medical Vidalia Clinicla is to document and track medical treatments and services provided to patients at the clinic.

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Information such as patient demographics, diagnosis, treatment plans, medications, and follow-up care must be reported on Trinity Medical Vidalia Clinicla.

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