WC Appointment Authorization

This form is for authorized agents only. Simply complete and submit the online authorization form below.

- Today's Date*
  Date Format: MM slash DD slash YYYY
- Date of Injury*
  Date Format: MM slash DD slash YYYY
- Patient's Name
  First Last
- Employer Name*
- Insurance Carrier*
- Nature of Injury*
- Authorization For*
  - Evaluation Only
  - Evaluation & Treatment
  - Medication Dispensing
  - Durable Medical Equipment Dispensing
- Authorized Agent Confirmation*
  - Yes
  Selecting yes confirms you are an authorized agent for the information completed above.
- Authorized Agent*
  First Last
  Entering your first and last name serves as a digital signature.
- Authorized Agent Phone*
- Authorized Agent Email*
- Please select best time to call*
- Please select your preferred TOI location*
- Yes, I would like to receive information and updates about the Orthopaedic Institute's physicians and services.*
  - Yes
  - No

Submit