Reliant urgent care authorization form 2026

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Click ‘Get Form’ to open the reliant urgent care authorization form in the editor.
Begin by filling in the employee information section. Enter the employee's name, employer, employee ID or badge number, department or division, date of injury, supervisor's name, today's date and time, and contact phone number.
In the 'Requested Services' section, specify whether the services are for a work injury or physical examination. Clearly indicate any drug screens required by selecting from options such as 5 Panel or 10 Panel.
If a drug screen is ordered, provide a reason for it in the designated field. Options include Post Accident, Return to Duty, Follow-Up, Random, and Pre-Employment.
Finally, ensure that an authorized person signs and prints their name in the 'Authorized By' section before submitting the form.

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