Charlotte Occupational Health Authorization for Work Related Injury Care

Occupational Health Services Charlotte

AUTHORIZATION FOR WORK RELATED INJURY CARE
Injury Care Locations and Service Hours
Sparrow Occupational Health Services Charlotte
through Sparrow Urgent Care Charlotte
Injury Care Hours: Monday-Friday from 8 a.m. to 7 p.m.
Weekends from 8 a.m. to 3 p.
Closed Major Holidays
616 Meijer Drive, Charlotte, MI, 48813
Phone: 517.364.3591 | Email: SparrowOHS@sparrow.org

* Children are not permitted to be with a parent/guardian during an occupational health visit. They may stay in the waiting room with proper supervision for the duration of the appointment.
Employee Information:
Patient's Name*
Date of Birth*

MonthDayYear
Authorizing Company*
Employee Email
Injury Information:
Date of Injury*

MonthDayYear
Description of Injury
Workers' Compensation Carrier*
Workers' Compensation Claim Number
Workers' Compensation Address
Post-Accident Drug and Alcohol Testing

(Photo Identifaction Required)
RAPID Urine Drug Tests:

4 Panel Rapid (No THC)5 Panel Rapid9 Panel Rapid (No THC)10 Panel Rapid11 Panel Rapid
I request and authorize the above-named employee to receive injury care from Sparrow Health Services.

I further understand that my company will be financially responsible for any and all authorized services in the event my workers compensation insurance carrier denies the charges for any reason.
Supervisor's Signature*

Clear
Printed Name*
Date*

MonthDayYear
Contact Phone Number*
Please enter a valid phone number.
Contact Email*
example@example.com
Please verify that you are human*
Should be Empty:

Occupational Health Services Charlotte

Injury Care Locations and Service Hours

Employee Information:

Injury Information:

Post-Accident Drug and Alcohol Testing