Forms

Treatment Authorization

To better serve you and your employees, please fill out the generic authorization form prior to your employee's visit. 

• E Authorization

Where to send your completed and signed authorization form:

• Send both pages of the completed form with your employee (preferred method to avoid delays).
• Fax both pages of the completed form to 260-458-5836.
• Email both pages of completed form to [email protected].

Treatment process

• Our staff will provide the services on the completed authorization form.
• If no authorization is provided, our staff will treat by following the company account, previously established with your Business Development Specialist.
• If services requested are not listed on your account, we will make an attempt to call your company for authorization of services to be performed. (This may cause delays for employee.) 

Appointment Request or Missing Results Form

You can use the form below to request an appointment or missing results. Complete the form thoroughly and send to [email protected].

• Appointment or Results Request Form

Once form is submitted, we will contact you to confirm appointment date, time, and location.

This form is not an authorization. Please send a Parkview custom authorization with your employee to their visit.

Parkview New-Hire Physical Exam Paperwork

Prior to your new hire physical exam appointment, please print and complete the following packet:

• Pre-Hire Packet

To schedule your pre-hire appointment, call 260-373-9300.

All forms in this packet must be completed and brought to your physical exam visit. If you have any questions about the Pre-Hire Packet, contact Employee Health Services, at [email protected].