Free D-32 - Nevada

AUTHORIZATION REQUEST FOR ADDITIONAL CHIROPRACTIC TREATMENT
PLEASE TYPE OR PRINT AND PROVIDE ALL OF THE INFORMATION REQUESTED
Claim Number

Name of Injured Employee Name of Employer Date of Last Treatment

REQUEST FOR ADDITIONAL CHIROPRACTIC TREATMENT
SSN # Date of Injury

Name of Treating Chiropractor Number of Treatments Since Injured's First Visit

DESCRIBE THE PRESENT CONDITION OF THE INJURED EMPLOYEE (Include Your Objective Findings, Symptoms, and Patient Complaints)

DEFINE AND GIVE THE NUMBER OF ADDITIONAL TREATMENTS FOR WHICH AUTHORIZATION IS REQUESTED:

Is the Injured Employee Capable of Working Now? Date

Give the Date By Which the Treatment Will Be Completed If Authorization is Granted: If "NO" Estimate the Date By Which The Employee [ ] YES [ ] NO Will Be Able To Return To Work: Signature and Address of Treating Chiropractic Physician Telephone Number

D.C.
FOR INSURER'S ACTION

[ ]
[]

AUTHORIZATION IS GRANTED FOR ADDITIONAL CHIROPRACTIC TREATMENTS. Other Action:

[ ]

Authorization for Additional Chiropractic Treatment is Denied

Date

Signature

Title

D-32

(rev. 7/99)