Title Page
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Authorization for Medical Treatment
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Employee Name
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Social Security #:
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Date of Birth
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Date of Injury
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To: Approved Provider
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The employee referenced above has reported an occupational injury/illness related to his/her employment. You are authorized to provide medically necessary treatment and/or prescription medications as they relate to the injury/illness reported
CONTROLLED SUBSTANCE AND ALCOHOL SCREENING REQUIRED
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The employee referenced above is required to submit to a controlled substance and alcohol screen upon the initial examination or emergency treatment. Please conduct the controlled substance and alcohol test on your panel. The results of said testing should only be reported to the employer.
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Authorized Manager:
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Date:
Accident/Injury Description:
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Manager Signature:
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Date:
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Pharmacy Information: Group # THF0100013 BIN: 009062 PCN: DCRx
AUTHORIZATION TO RELEASE MEDICAL RECORDS
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You are hereby authorized and directed to release any and all information you may have regarding my condition while under your observation and treatment at any time. This information includes but may not be limited to medical history and findings, consultation, prescriptions, medical treatment, x-rays and other diagnostic testing results, consultation reports, narrative reports, diagnosis, prognosis, surgical reports and all hospital records and reports.
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All medical records and information should be sent to:
Charlie Harrington, Safety Coordinator
US Concrete, Inc.
331 N Main Street
Euless, TX 76039
Phone: 817-835-4039
Fax: 817-835-4162
CHarrington@US-Concrete.com -
State Law requires that you be notified that the information you authorize for release may include information about communicable and venereal diseases which may include, but may not be limited to diseases such as Hepatitis, Syphilis, Gonorrhea, Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). 63 O.S. Supp. 1992 Section 1-502.
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Employee Signature:
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Date:
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ELECTRONIC/PHOTOSTATIC COPIES OF THIS AUTHORIZATION HAVE THE SAME AUTHORITY AS THE ORIGINAL
