Treatment Authorization and Other Forms

• New Company Information Form - Provides information about your company that we need in order to communicate with your Worker’s Compensation carrier and provide you with reports, results and other documentation. Please fax your completed form to the Urgent Care Center closest to your primary business location.
• Treatment Authorization Form - Enables employers to specify what kind of testing and treatment an employee needs and to authorize MidMichigan to provide those services. Employers may complete this form and have the employee bring it to his or her appointment or fax it to one of our Urgent Care Centers in advance of an appointment.
• OSHA Respirator Fit Questionnaire - Gathers personal history and health information that our medical professionals will need to verify that an employee is medically fit to wear a respirator. Please have the employee complete the questionnaire and bring it to his or her appointment.
• MIOSHA Known Occupational Disease Reporting Form - Employers must report known or suspected cases of occupational diseases or workplace aggravated health conditions to the Michigan Department of Licensing and Regulatory Affairs within 10 days after discovery. in cases of workplace illness, please complete the Employee and Employer portions of this form and as much of the Illness Information as you are able and then send it with the employee to their Occupational Health appointment.