Occupational Health Forms
If you are interested in receiving more information about a FastMed Urgent Care corporate account, please fill out the above application completely. Once the form is complete please email it to OccMed@fastmed.com and a sales representative in your area will contact you to initiate the account set up process.
Please use this form for all new workers’ compensation visits. Every new injury and subsequent claim requires a new form to be filled out even if the patient has visited FastMed for a previous injury.
NOTE: Account setup must be completed before Charge Authorization Form may be used.
Please provide every patient with an authorization form, completed and signed by an authorized organizational representative. This form verifies that FastMed may bill the services performed to your organization and that your organization agrees to pay for the performed services.