Treatment Authorization Form

• This form may be printed and used to direct an injured worker to the nearest MED7 clinic. It has a convenient map, hours of operation and telephone numbers, and a listing of services. MED7 maintains a database of routine services for your company. We realize those services may need to be altered on a case-by-case basis. This form can be used for that purpose.

• This form is used to set-up an account for pre-employment services. Once completed, please fax to (916) 483-1937. A representative will contact you shortly.

• This form is used to designate MED7 as the facility of choice for your injured workers. Please complete and fax to (916) 483-1937. A representative will contact you shortly.

• If you have arranged for a Respiratory Clearance Examination for an employee, please print and provide this form to that employee at least 2-3 days BEFORE the exam. If you are requesting a mandatory physical and spirometry, have the employee bring this completed form in with him/her at the time of the physical.
• If you are NOT requesting a mandatory physical, this form should be completed and faxed to our clinic at (916) 973-0158, for review by one of our providers. Once the form is reviewed a determination will be made whether or not to proceed with a physical examination and spirometry. You will be notified promptly.

• If you have arranged for an OSHA compliant physical, provide your employee with this form 1-2 days in advance of their scheduled appointment. The employee should complete their sections, and bring the form in with them at appointment time.