Work Comp - Employer Services Auth

Employer Services / Workers' Compensation Authorization Form

If you have an existing employer protocol with OrthoIllinois, please use this form to authorize an employee for treatment or testing.
Do you have an Employer Protocol on file with OrthoIllinois?

YesNo
Employer Protocol Required!

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. Our team will contact you at their earliest convenience during regular business hours.

Click here to receive a callback from the OrthoIllinois Business Development Team.
Don't Forget to hit "SUBMIT" at the bottom of this page once you've completed this form!
Which Injury Express location would you like to use?*
I am authorizing an employee to be seen for:*

A Suspected Work-Related Injury (Includes Injury Evaluation by a Provider)An Employment Exam or other Occupational Testing (Substance Abuse Testing, pre-employment exams, DOT)
Authorization Expiration Date

MonthDayYear
Date
Employer / Company Name
Please enter the name of your business above.
Employer City

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Who is authorizing this employee for treatment / testing?
Please enter the name of the authorized manager above.
Best Contact Number
Please enter a valid phone number.
If you'd like an email copy of this form, please enter your email here.
example@example.com
Signature of authorizing manager

Clear
Employee / Applicant Name
Employee / Applicant Job Title
Injury Care

Please enter information regarding the employee's injury below.
Date of work-related injury/incident

MonthDayYear
Date
Body Part(s) approved for treatment
Post-Accident Substance Abuse Testing Needs:

Medical Evaluation ONLY. (NO Drug Screen or Alcohol Testing required)Medical Evaluation WITH Substance Abuse Testing.
Which Post-Accident Urine Drug Test is required? (Rockford)
Which Post-Accident Urine Drug Test is required? (Algonquin / Elgin)
Is a Post-Accident Breath Alcohol Test required? If so, which test?
Anything additional you would like to tell our team regarding this incident?
Employer Services Program / Testing

New / Current Employees
For ALL Employer Services Testing at OrthoIllinois:
- If your employee is coming for employment physicals or drug screens, please arrive prior to 7:15 PM on weekdays / 1:15 PM on weekends.
- Please do NOT bring children with you for your visit unless you are accompanied by someone that will be responsible to care for them.
Is the Employee responsible for payment for some or all of this testing?

YesNo
Please select the testing that will be charged to your employee at the time of service:

Pre-Employment / Post-Offer Physical Exam = $75DOT Exam (New) = $150Federal 5-panel Urine Drug Screen = $65DOT Exam (Recertification) = $150TB Mantoux Skin Test = $32
Total due by your employee at the time of service
Rockford - Please select the Employer Services EXAMS Required: (Billed to the employer)

Pre-Employment / Post-Offer Physical ExamDOT Exam (New)DOT Exam (Recertification)School Bus Driver ExamDCFS Form (New / Bi-Annual)Lift Test - 25 pounds (Performed by Injury Express Provider)Lift Test - 50 pounds (Performed by Injury Express Provider)Pre-Employment Back Assessment. (In Rehab Department. These exams are NOT performed after 5 pm Weekdays, or on Weekends.)NO Employer Paid Physical Exams required.
Eastern - Please select the Employer Services EXAMS Required: (Billed to the employer)

Pre-Employment / Post-Offer Physical ExamSchool Bus Driver ExamLift Test - 25 pounds (Performed by Injury Express Provider)Lift Test - 50 pounds (Performed by Injury Express Provider)NO Employer Paid Physical Exams required.
Is a Urine Drug Test is required? (Rockford)
Is a Urine Drug Test is required? (Algonquin / Elgin)
What is the reason for the Urine Drug Test?

Pre-EmploymentReturn to dutyRandomFollow-upAnnualReasonable SuspicionPost-Accident
Is a Breath Alcohol Test required? If so, which test?
What is the reason for the Breath Alcohol Test?

Pre-EmploymentRandomFollow-upReasonable SuspicionPost-Accident
Other Employer Services TESTING Requested:

AccucheckAudio ScreenBlood Pressure CheckCotinine (Nicotine) Urine TestHepatitis B Titer / Lab DrawHepatitis B VaccinationOSHA Lead & ZPP EvaluationRBC CholinesteraseTB QuantiFeron Gold (Lab Test)TB Mantoux (Skin Test)TDAP VaccinationUrine Dip - No MicroVision ScreeningX-Ray / ChestX-Ray / LumbarOther
Anything else you'd like our team to know?
Should be Empty:

Employer Services / Workers' Compensation Authorization Form

Don't Forget to hit "SUBMIT" at the bottom of this page once you've completed this form!

Injury Care

Employer Services Program / Testing