Treatment Locations and Authorization Forms • SURESTAFF

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Treatment Locations and Authorization Forms

Please select your state.

Arizona

Authorization for Examination or Treatment

Arizona Work Injury Clinic Locations – MBI Inc

Banner Urgent Care

MBI Authorization Form

Connecticut

AFC Urgent Care Authorization Form

AFC Urgent Care Locations

Florida

Patients First Authorization Form

Concentra – Doral

Georgia

Albany Doctors Panel Locations

Lithia Springs Doctors Panel Locations

Thomasville Doctors Panel Locations

GA Panels of Physician Compliance

Georgia Panel – McDonough

Illinois

Belvidere Ortho Illinois Authorization Form

DIL Authorization Form

Local MD Fillable Med Auth Form

Occupational Health Services all Locations

Well Now/Physicians Immediate Care Authorization Form

Well Now/Physicians Immediate Care Locations

Work injury Care Zion

Indiana

Indianapolis – Concentra Authorization Form

Indianapolis – Concentra Indiana Locations

Crawfordsville – Franciscan Indiana Locations

Crawfordsville – Franciscan Authorization Form

Deaconess – Authorization Form

Deaconess – Clinic Locations

Evansville – Mercy Indiana Locations

Evansville – Mercy Indiana Authorization Form

Kentucky

Fastpace Health Authorization From

Fastpace Health Clinic Location

Versailles – Concentra Nicholas Urgent Care

Lebanon Junction – Baptist Health Occupational Medicine

Maryland

Authorization for Examination or Treatment

Concentra SMD Contractor Location Listing

Massachusetts

AFC Urgent Care Authorization Form

AFC Urgent Care Locations

Michigan

Corewell Health Occupational Grand Rapids Location

Corewell Health Authorization Form

Henry Ford Health Authorization Form

Lansing Sparrow Heath Authorization Form

Lansing Work Health Authorization Form

Lansing Memorial Healthcare Authorization Form

1^st Choice Authorization Form

Mississippi

Mississippi Choice of Physician’s Form

Mississippi Authorization From

Mississippi Clinic Location

Missouri

NKC Health (Meritas) Authorization Form

NKC Health (Meritas) Location Map

New Jersey

CityMD Injury and Illness Call In Procedure

CityMD New Jersey Locations

Ohio

Fremont – Promedica360 Health Authorization Form

Hometown Urgent Care Authorization Form

Minster – Hometown Urgent Care Locations

Mercy Health Occupational Fairfield Location

Concentra Columbus West Location

Toledo Area – Concentra Authorization Form

Toledo Area – Great Lakes Urgent Care Authorization Form

Toledo Area – Northwest OH Urgent Care Authorization Form

Pennsylvania

Concentra Authorization Form

Pennsylvania Physicians Panel Indiana

Pennsylvania Physicians Panel Gap

Pennsylvania Physicians Panel Hazle Township

Pennsylvania Physicians Panel Levittown

Pennsylvania Physicians Panel Lititz

Pennsylvania Physicians Panel Pittston

Pennsylvania Physicians Panel Wilkes Barre

Rhode Island

AT Med Authorization Form

AT Med Treatment Center Locations

Tennessee

Tennessee Choice of Physician Form

Concentra Memphis

Concentra Authorization Form

AFC Authorization Form

Baptist Minor Medical Center – Memphis | Walk-In Clinic

Texas

The Port Authorization Form

The Port Occupational & Medical Clinic

Concentra Authorization Form

Concentra Texas Locations

Wisconsin

Beloit & Darien – Mercy Authorization Form – Wisconsin

Beloit & Darien – Beloit Health System Location

Beloit & Darien – Mercy Health Location

Froedert South – Locations

Froedert South – Authorization Form

Kenosha – Concentra Authorization Form

Kenosha – Concentra Wisconsin Locations