New Patient Referral Authorization Form

DOB*

Patient Email

Patient Phone #*

Patient Gender

Date of Injury/Symptom Onset*

Social Security #

Patient Primary Language*

This field is hidden when viewing the form

Condition Full

This field is hidden when viewing the form

Laterality Full

This field is hidden when viewing the form

Treatment String

Jurisdiction State*

Employer*

Employer Phone #

Occupation*

This field is hidden when viewing the form

If yes, indicate where, records must be provided (old)

Case Manager Phone #

Case Manager Email

Case Manager Fax #

Work Comp Payer/TPA/Carrier*

WC Claim #*

This field is hidden when viewing the form

Work Comp payer email

This field is hidden when viewing the form

Approval Date

Adjuster Phone #*

Adjuster Email*

Adjuster Fax #*

Comments

File attachments*

At minimum, please attach the First Report of Injury (FROI). If the patient has undergone diagnostic testing or other evaluations, please attach those records as well.

Drop files here or

Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 4 MB.

Date*

Adjuster and/or Employer Signature*

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

This field is hidden when viewing the form

Description of Incident

This field is hidden when viewing the form

Employer address

This field is hidden when viewing the form

Billing address*

This field is hidden when viewing the form

File attachment (single/old)

Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 2 MB.

This field is hidden when viewing the form

Bill review company (old)

This field is hidden when viewing the form

Bill Review Company Phone # (old)

New Patient Referral Authorization

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