New Patient Referral Authorization

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Patient Name*
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Patient Address*
YYYY dash MM dash DD
Condition*
Laterality:*
Employer Address*
Has this patient received a diagnosis and or treatment?*
Has surgery occured for this injury?
Please check all that apply, if this patient has had any of the following:
Case Manager Name
Payer Address
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MM slash DD slash YYYY
Adjuster Name
YYYY dash MM dash DD
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Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 4 MB.

    By signing the New Patient/Authorization form, you are authorizing and agreeing to pay MinWorx Health the Global Bundled fee detailed in the letter of agreement within 30 days of receipt of invoice.

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    Condition (old):
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    Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 2 MB.

    *This is a secure form (It is encrypted both at rest and in transit and is HIPAA compliant.)

    Elevating the service model and outcomes for the injured worker who needs surgical care.

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