Clineva WorksOccupational health
(844) 254-6382 Send a worker

Print & bring to the clinic

Employer treatment request.

Print this blank form, complete it offline, and send it with the employee. Call the clinic to confirm authorization and billing requirements.

Clineva WorksOccupational health

(844) 254-6382
www.clineva.works

Employer treatment request

Complete offline and bring to the clinic. This request is subject to clinic review and does not confirm insurer authorization, network coverage, or acceptance of a claim. It is not a DWC-1 claim form.

Employer & employee

Company / employer name
Date of request
Employee name
Requested clinic
Employer contact name and title
Employer contact phone

Requested service

Workplace injury evaluationPre-employment physicalDOT physical (call ahead)Drug screening (confirm panel)Return-to-work evaluationOther (specify below)
Service instructions / required employer paperwork

Claim & billing details, if applicable

Workers’ compensation carrier / administrator
Claim number, if available
Adjuster contact and phone
Employer billing contact and phone

Employer representative

I am requesting that the clinic review the services indicated above. Clinical care, authorization, and billing arrangements must be confirmed with the clinic.

Representative signature
Date

Do not email completed forms or employee health information through the website’s general inquiry. Contact the clinic for an appropriate way to share documents. For a medical emergency, call 911.