1-15-2018
INTENT TO TREAT
Employee’s Name______________________________________________
(PLEASE PRINT)
From ________________ forward I intend to treat with
(date of first appointment)
_____________________________________________________________
(physician/hospital)
_____________________________________________________________
(address, city, state zip)
_____________________________________________________________
(phone & fax number)
regarding an injury received to my _______________ on _______________
(body part) (date of injury)
which I claim arose out of or in the course of my employment at Ferris State
University.
I hereby authorize and request the above listed physician/hospital to give
Ferris State University or any representative thereof, any and all information
regarding examinations, diagnosis, prognosis and treatment of the above
mentioned injury. A similar intent to treat form will be required prior to
treating with a physician or hospital not named above. A photocopy of this
authorization shall be considered as effective and valid as the original.
________________________
(Employee Signature)
________________________
(Date)
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