Quality Urgent Care

quc@qualityurgentcare-riverview.com

(813) 741-2592

Employer Authorization
For Services

Quality Urgent Care Location (Name & Address):

Employee Name:

Employee Date of Birth:

Employer Name:

EScreen Account #:

Employer Address:

Employer Phone Number:

Contact Name:

Existing Account:

Yes No

Would you like us to contact you to set up an account?

Yes No

Choose Bill To

Employee Self Pay

Employer Paid

Attention To:

Via (email, fax, mailing address):

Workers Compensation

Carrier:

Contact Information:

I authorize Quality Urgent Care to treat the employee listed above for the services selected.

Authorized Designated Employee Representative,

Date

Quality Urgent Care reserves the right to refuse treatment without employer authorization. Services provided without proper authorization will be billed as the patient's responsibility. Services may vary by location. To confirm services and availability, please contact Quality Urgent Care at (813) 741-2592.

Quality Urgent Care

Employer Authorization
For Services

Choose Bill To

Workers Compensation

Physical Examination Needed

Urine Drug Screening Needed

Titers Needed

Vaccinations Needed

Additional Services Needed