WCFT/ESP Authorization

You're using an outdated link to access this form. Please click here to access the updated online authorization form.

Download the newest PDF version of this authorization form by clicking HERE.

You may also find the most up-to-date documentation on our website at https://www.orthoillinois.com/occupational-health-center/
Authorization Form

If you have an existing employer protocol with OrthoIllinois, please use the form below to authorize an employee.
Do you have an Employer Protocol set up with OrthoIllinois?*

Yes, I have an existing employer protocol on file.No, I do not have a protocol on file and need to set one up.
Employer Protocol Required!

In order to utilize this online form, an employer protocol must be completed in advance.

Please contact the OrthoIllinois Business Development team during regular business hours at 815-398-9491 for more information, or use the link below.

If you would like our team to contact you and set up a protocol, please click here.
What Injury Express Location would you like to use?*
I am authorizing an employee to be seen for:*

A Suspected Work-Related InjuryAn Employment Exam or Testing
Authorization Date*

MonthDayYear
Date
Authorization Expires*

MonthDayYear
Date
Employee/Applicant name*
Job Title
Employer name*
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number*

Area CodePhone Number
Name of Company Representative Authorizing This Visit*
Authorized Signature*

Clear
Please fill out below if authorizing for a work related injury.
Post Accident Substance Abuse Testing Needs (Please select all that apply)

Medical Evaluation only. (NO drug screen or alcohol testing)Medical Evaluation WITH substance abuse testing. (Add required testing below)Add Urine Drug Screen to the Medical Evaluation.Add Breath Alcohol Testing to the Medical Evaluation.
Date of work related injury/incident

MonthDayYear
Date
Body Part(s) Approved for Treatment
Anything additional you would like to include for our team?
Please use the section below for Employment Exams

New / Current Employees (Employer Services Program)
What type of exam do you need?

Pre-Employment / Post Offer - FactoryPre-Employment / Post Offer - OfficeDOT Exam (New)DOT Exam (Recertification)School Bus Driver ExamThe applicant requires a Lift Test. (performed by our Provider)Other
If a Urine Drug Test is needed, Non- Federal or Federal?

Non-FederalFederal
What is the reason for the Urine Drug Test?

Pre-EmploymentReturn to DutyRandomFollow-UpAnnualPost-AccidentReasonable Suspicion
If a Breath Alcohol Test is required, Non-Federal or Federal

Non-FederalFederal
What is the reason for the Breath Alcohol Test?

RandomReasonable SuspicionFollow-UpPost-Accident
Additional Testing (Non Patient File)

Hepatitis B / Lab DrawHepatitis B VaccinationTB QuantiFeron GoldTB MantouxLumbar X-RayChest X-RayAudio ScreenBlood Pressure CheckVision CheckPre-Employment Back Assessment. (in Rehab Dept. These exams are NOT performed after 5 pm Weekdays or on Weekends)Other
Should be Empty:

Authorization Form

Please fill out below if authorizing for a work related injury.

Please use the section below for Employment Exams