Authorization for Treatment - East Jefferson General Hospital

Fields marked with an asterisk(*) are required.
General Information
- Employee's Name*
- Injury Date*
  MM slash DD slash YYYY
Injury Time*

: Hours

Minutes

AM/PM
Section Break
Employer Information
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
- Phone*
- Person Authorizing Treatment*
Section Break
Reason(s) For Visit (Please select all that apply.)
- Physical Exam Needed?
  - Yes
  - No
- Physical Exam Type
- Urine Drug Test
  - Federal (DOT/CDL)
  - Non Federal (State)
- Reason for test
- Alcohol Test
  - Screen
  - Evidential Breath
  - Blood
- Injury
  - Workers' Comp
  - General Liability
Additional Testing/Comments:
Please note: Upon form completion, EJGH will forward your employee's information to Pelican State Occupational Medicine. They will be providing any applicable evaluations, treatments, and return to work status letters.
Pelican State Urgent Care
1525 Dickory Ave., Harahan, LA 70123
Monday - Friday, 8 a.m. to 11 p.m.
Saturday - Sunday, 9 a.m. to 5 p.m.
Name
This field is for validation purposes and should be left unchanged.

Section Break