Fill and Sign the Authorization Request for Additional Chiropractic Treatment Form

AUTHORIZATION REQUEST FOR ADDITIONAL CHIROPRACTIC TREATM ENT PLEASE TYPE OR PRINT AND PROV IDE ALL OF THE Claim Number INFORM ATION REQUESTED REQUEST FOR ADDITIONAL CHIROPRACTIC TREATM ENT Name of Injured Employ ee SSN # Dat e of Injury Name of Employ er Name of Treat ing Chiropract or Dat e of Last Treat mentNumber of Treat ment s Since Injured' s First V isit DESCRIBE THE PRESENT CONDITION OF THE INJ URED EM PLOYEE (Include Your Object iv e Findings, Sy mpt oms, and Pat ient Complaint s) DEFINE A ND GIV E THE NUM BER OF A DDITIONA L TREA TM ENTS FOR W HICH A UTHORIZA TION IS REQUESTED: Giv e t he Dat e By W hich t he Treat ment W ill Be Complet ed If A ut horizat ion is Grant ed: Is t he Injured Employ ee If "NO" Est imat e t he Capable of W orking Now ? [ ] YES [ ] NO Dat e By W hich The Employ ee W ill Be A ble To Ret urn To W ork: Dat e Signat ure and A ddress of Treat ing Chiropract ic Phy s icianTelephone Number D. C. FOR INSURER' S ACTION [ ] A UTHORIZA TION IS GRA NTED FOR [ ] A ut horizat ion f or A ddit ional Chiropract ic A DDITIONA L CHIROPRA CTIC TREA TM ENTS. Treat ment is Denied [ ] Ot her A ct ion: Dat e Signat ure Tit le D-3 2 (rev . 7 / 9 9 )