Authorization to Treat Form
Please contact one of the following:
Elaine Lewis, 269-978-4169
Dan Herder, 269-978-4112 (c) 269-365-3971
Dan Nielsen, 708-288-6103 email@example.com
If you are unable to contact one of the above at the phone number given, please submit an e-mail statement to Dan Nielsen at the address show above, with a short description of the services needed and your contact information. Let this serve as “Authorization to Treat”.
** 10 Panel Drug Test required for all work-related injuries **