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\\vmstorage\MKTShare\Forms\FinalForms\WRI TA Updated 1/28/2019
Work-Related Injury Treatment Authorization
Urgent Care | Occupational Medicine Open Everyday 8am –11pm | Select Locations Open 24 Hours
www.texasmedclinic.com
Physician Evaluation Only
Physician Evaluation & Post Accident Testing
MEDICAL EVALUATION BILLING INFORMATION
Name of Workers Comp Insurance (if applicable) :
Billing Address:
Phone: Fax:
Email:
If you are a subscriber, are you in a Network? Yes No
Please indicate name of Network: ______________________________________________
Workers Comp Billing Contact:
Name:
Phone:
Fax:
Email:
Employee Name: ________________________________________________________________________________
Job Title: ____________________________ Social Security #: ______________________ DOB:_________________
Date of Injury:_____________________________ Claim # (if applicable) :_______________________
Company Name: ______________________________________________________ Employer ID # _________________ Address: __________________________________________________________________Store # __________________ Phone: ____________________________________ After Hours Phone: ______________________________________ Person Authorizing (Please Print): ________________________________________________ Title: ________________
(This form is to be used as authorization to evaluate and treat an injured worker. If you only require drug testing services, please use Occupational Treatment Authorization.)
In order to treat your work-related injury, Texas MedClinic MUST obtain the bill-ing information for either your employer or your employer’s Workers Compensa-tion insurance. State laws set forth by the Division of Workers Compensation prohibit medical providers from billing or accepting payment from the patient for the treatment of work-related injuries if the company has Workers Compensation Insurance. If we CANNOT determine if your employer has insurance for work-related injuries OR proper billing information for your employer, our providers will ensure that you are medically stable and then you MAY be referred to the emergency room for further evaluation and treatment.
POST ACCIDENT DRUG & ALCOHOL TESTING
*WRITA*
Electronic (Form Fox)
Employee will hand
carry
Forms on file at clinic
Chain of Custody Form
RAPID DRUG TESTING*
5 Panel
10 Panel
*Non-DOT - Texas MedClinic lab only. Same day
negative results before 2 pm. Specimens
requiring further testing can take 2-7 business
days depending on results and date/time of
BREATH ALCOHOL TESTING
Non-DOT
DOT
NON-DOT DRUG TESTING
5 Panel
10 Panel
Hair Drug Test
DOT DRUG TESTING
DOT Drug Test
DOT Testing Agency
DOT Testing Authority
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT
HHS
NRC
DISA
CMI
HireRight
Consortium/Third Party Administrator
Onsite Services
FleetScreen
Other: _____________
Updated 8/21/2018
WURZBACH IH10 W/ Wurzbach (24 Hour) 9885 IH-10 West San Antonio, TX 78230 Ph: (210) 696.5599 Fx: (210) 699.8152 Clinic Manager: Jessica Elizondo Clinic Medical Director: James Bugg, MD occmed.wz@texasmedclinic.com
CULEBRA Loop 1604 / Culebra (24 Hour) 6530 W Loop 1604 N San Antonio, TX 78254 Ph: (210) 476.5577 Fx: (210) 688.9334 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: John Cantu, MD occmed.cu@texasmedclinic.com
FORUM IH 35 N / Loop 1604 (24 Hour) 8341 Agora Pkwy San Antonio, TX 78154 Ph: (210) 659.5533 Fx: (210) 659.7755 Clinic Manager: Dan Sookchan Clinic Medical Director: James Murray, MD occmed.fm@texasmedclinic.com
LEON SPRINGS IH 10 W / Leon Springs 23611 IH 10 West • San Antonio, TX 78257 Ph: (210) 698.6617 | Fx: (210) 698.6627 Clinic Manager: Eddie Thomas Clinic Medical Director: Clayton Pullin, MD occmed.ls@texasmedclinic.com
EISENHAUER IH 35 N / Eisenhauer 7460 IH 35 North • San Antonio, TX 78218 Ph: (210) 655.5529 | Fx: (210) 655.5504 Clinic Manager: Jenny Lopez Clinic Medical Director: Angela Scalzi, MD occmed.es@texasmedclinic.com
BLANCO Blanco / Parliament 11811 Blanco Road • San Antonio, TX 78216 Ph: (210) 341.5588 | Fx: (210) 341.7513 Clinic Manager: Ernest Delao Clinic Medical Director: James Bugg, MD occmed.bl@texasmedclinic.com
BROADWAY Loop 410 / Broadway 1007 NE Loop 410 • San Antonio, TX 78209 Ph: (210) 821.5598 | Fx: (210) 829.0125 Clinic Manager: Jenny Lopez Clinic Medical Director: James Murray, MD occmed.br@texasmedclinic.com
SOUTHEAST SE Military / Roosevelt 1111 SE Military • San Antonio, TX 78214 Ph: (210) 927.5580 | Fx: (210) 927.2700 Clinic Manager: Diana Barajas Clinic Medical Director: Brian Raimondo, MD occmed.se@texasmedclinic.com
BANDERA Loop 1604 / Bandera 9207 N Loop 1604 West • San Antonio, TX 78249 Ph: (210) 695.4884 | Fx: (210) 695.4949 Clinic Manager: Eddie Thomas Clinic Medical Director: Jeffery Weaver, MD occmed.bn@texasmedclinic.com
INGRAM Ingram/Loop 410 6570 Ingram Road • San Antonio, TX 78238 Ph: (210) 520.5588 | Fx: (210) 522.1125 Clinic Manager: Ernest Delao Clinic Medical Director: Paula Lyons, MD occmed.ig@texasmedclinic.com
STOTZER Hwy 151 / Loop 410 8519 State Hwy 151 • San Antonio, TX 78245 Ph: (210) 682.5577 | Fx: (210) 647.5566 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: Joseph Elizondo, MD occmed.sz@texasmedclinic.com
STONE OAK 1604 / Stone Oak Pkwy 323 N 1604 West • San Antonio, TX 78232 Ph: (210) 549.5893 | Fx: (210) 549.5894 Clinic Manager: Shannon Fletcher Clinic Medical Director: Paula Lyons, MD occmed.so@texasmedclinic.com
Locations | San Antonio/New Braunfels
SOUTHWEST SW Military / Zarzamora 2530 SW Military Drive • San Antonio, TX 78224 Ph: (210) 476.5599 | Fx: (210) 455.9217 Clinic Manager: Diana Barajas Clinic Medical Dir: Brian Raimondo, MD occmed.sw@texasmedclinic.com
NEW BRAUNFELS IH 35 N / Hwy 46 958 IH 35 North • New Braunfels, TX 78130 Ph: (830) 606.5533 | Fx: (830) 606.5535 Clinic Manager: Destiny Cortez Clinic Medical Director: Ami Beshay, MD occmed.nb@texasmedclinic.com
OAK RUN Hwy 46/Oak Run Pkwy 1922 S State Hwy 46 W • New Braunfels, TX 78132 Ph: (830) 632.5092 | Fx: (830) 632.5094 Clinic Manager: Destiny Cortez Clinic Medical Director: Laura Perez, MD occmed.or@texasmedclinic.com
Locations | Austin/Round Rock
SOUTHPARK MEADOWS IH 35 S / Slaughter Lane 9900 South IH-35 • Austin, TX 78748 Ph: (512) 291.5577 | Fx: (512) 291.5576 Clinic Manager: Julie Koenning Clinic Medical Director: Glenda Peters-Do, MD occmed.sp@texasmedclinic.com
ROUND ROCK IH 35 N / Bass Pro Drive 4851 N IH 35 • Round Rock, TX 78664 Ph: (512) 486.6140 | Fx: (512) 863.4285 Clinic Manager: Kelly Bilsky Clinic Medical Director: Kristen Kocurek, MD occmed.rr@texasmedclinic.com
PARMER N MoPac / Parmer 12319 N MoPac Expy • Austin, TX 78758 Ph: (512) 835.5577 | Fx: (512) 836.0166 Clinic Manager: Juanita Peka Clinic Medical Director: Kristen Kocurek, MD occmed.pr@texasmedclinic.com
SINGING HILLS Hwy 281/Hwy 46 426 Singing Oak • Spring Branch, TX 78070 Ph: (830) 632.5740 | Fx: (830) 632.5743 Clinic Manager: Shannon Fletcher Clinic Medical Director: Angela Scalzi, MD occmed.sh@texasmedclinic.com
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