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Patient Services
Virtual Care
Occupational Services
- Occupational Contract
- Authorization for Services
Careers

Home
Patient Services
Virtual Care
Occupational Services
- Occupational Contract
- Authorization for Services
Careers

Authorization for Services

Please Fill out form with the name of the employee you are sending for services and select the services needed.

Authorization for Occupational Medicine Services

Employee Name(Required)

First Last

Company Address

Street Address Address Line 2 City ZIP Code

Company Contact

Please enter company contact name, email, phone and fax.

Company Contact Person/ DER

Company Email Address(Required)

Email Address Confirm Email Address

Company Phone

Company Fax

Exam/ Evaluation Services Needed

DOT Physical Exam

School Bus Physical

Pre-Employment/Work Physical

Post Injury Assessment

TB Screening (PPD)

Spirometry (Pulmonary Function Testing)

Respirator Fit Testing

Chest X-Ray

EKG (Electrocardiogram)

Blood Pressure Check

Please check the box beside the services needed.

Drug Screening/ Substance Abuse Screening Services

DOT Urine Drug Screen (With MRO Review)

Non-DOT Urine Drug Screen (With MRO Review)

In-House 5 panel rapid Urine Drug Screen

In-House 11 panel rapid Urine Drug Screen

Breath Alcohol Testing

Please select the services needed.

Type of Drug Screen(Required)

Pre-Employment

Post Accident

Random

Reasonable Cause

Follow-Up

Return to Duty

Observed or Non-Observed(Required)

Non-Observed

Observed

Work Injury Evaluation and Treatment

Who Is paying for visit? (Workers' Comp or Employer)

Workers’ Compensation Insurance

Employer

Workers' Compensation Carrier

Name of Insurance Carrier

Workers' Compensation Carrier Phone Number

What is the phone number for your workers’ comp carrier

Workers' Compensation Policy Number

What is the policy number

Workers' Compensation Claim Number

What is the claim number (a claim number tied to this injury)

Date of Injury(Required)

Comments/ Questions

Name of the person submitting the form(Required)

First Last

Your Position in Company

Consent

I acknowledge that my company will be billed directly for all services rendered unless valid third-party coverage (such as worker’s compensation insurance) is provided at the time of visit.

About Our Practice

Ambient Care was started with the objective of giving the community a convenient place for healthcare. We offer a wide array of Urgent Care services. Our model is focused on treating one person at a time with an effective and efficient system in the background. We strive for excellence in care. Our branch locations are wholly owned and operated by us.

Corporate Office

Address:

24459 Sussex Highway
Suite 2 • Seaford, DE 19973

Phone:

Email:

yourcare@ambientmedicalcare.com

Career Opportunities

Click here to explore working with us.

Our Locations

Ambient Care Seaford
Walk-in Care
877-629-2621
24459 Sussex Hwy, Suite 2
Seaford, DE 19973

Hours:
Mon – Fri: 8am – 8pm
Sat – Sun: 9am – 5pm

Ambient Care Milford
Telemedicine (learn more)
877-629-2621
637 N. Dupont Blvd
Milford, DE 19963

Hours:
Mon – Fri: 8am – 7pm
Sat – Sun: 9am – 5pm

Privacy Policy

Terms of Services