CorporateCare Authorization to Treat Form

Location of Care *

Lenexa - 11140 Thompson Avenue, Lenexa, Kan. 913-492-9675North Kansas City - 2025 Swift, North Kansas City, Mo. 816-221-0058Lee's Summit - 805 NE Rice Road, Lee's Summit, Mo. 816-554-1518KCI - 10090 NW Prairie View Road, Kansas City, Mo. 816-880-9994

Personal Information

Patient's Name * First Middle Last

Employer * Enter employer's name

Address *

Street Address City State Postal / Zip Code

Work Phone * ###-###-####

Treatments

Work Related

yes

Part of body involved

Description of injury Describe the injury

Date of injury mm/dd/yyyy

Time of injury Use military time

Post accident testing

Substance abuse testing

NIDA (DOT) Urine Drug ScreenNon-NIDA (Non-DOT) Urine Drug ScreenBreath Alcohol Screen

Reason for testing

Post-OfferPost-AccidentReturn to DutyFor CauseRandomFollow-UpOther

Other

Emergency Department Information

Authorized by*

By clicking this box, you agree that the above information is correct and without error *

yes

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913-676-2000

9100 West 74th Street

Shawnee Mission, Kansas 66204

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