ASSOCIATES IN ORTHOPAEDICS & SPORTS MEDICINE

Up to date.
Down to earth.
Close to home.


Get advanced,high-quality care right here in Dalton.

J.Mitchell Frix, MD
Charles H. Herndon, Jr., MD
John T. Norman,Sr., MD
Michael D. Wilson, MD

Call 706.226.5533



AUTHORIZATION FOR WORKER'S COMPENSATION

Date: Appointment Date:   Time:    

Dr:

PATIENT INFORMATION:

Last Name:   First Name:

DOB:            SS#:

Home#:    Work#:

Date of Injury:   

Claim #:

Injury/Diagnosis:

Right Left Bilat X-Rays MRI

Referring Dr:   

Other Tests: 

EMPLOYER INFORMATION:
 
Name:       


Address:   

                   

Telephone:   Ext:   Fax#:

Contact Person:

WORKER'S COMPENSATION CARRIER:

Name:    

Address:

                

Telephone: Ext: Fax#:

Adjusters Name:
 
Authorization to be: Faxed   Sent w/Patient   Emailed