Workman's Compensation Authorization

Patient’s Name

Date of Birth

Patient’s Employer

Date of Injury

Worker’s Compensation Coverage provided by

Address

Claim Adjuster

Phone #

Claim #

Fax: 252-443-7114

Email: appointments@pfacnc.com

Services Authorized:

Evaluation Only Evaluation and Treatment Evaluation and Treatment and Follow Up Care Durable Medical Equipment # of visits authorized

W/C benefits verified by

Date

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