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Employer forms
Use these forms to authorize treatment of an injured or sick employee as well as to open an account with your clinic and establish a payment method.
Please email forms to customercare@akesomedical.com
Chula Vista / National City
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Commerce
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
El Centro Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Huntington Beach Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Irvine Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Lakewood Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
La Mirada Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Mission Valley Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
National City Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Oceanside Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Oxnard Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Paramount Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Riverside Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
San Diego Downtown Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Santa Fe Springs North Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Santa Fe Springs South Clinic
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Santa Maria Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
TREATMENT AUTHORIZATION-PRV
Autorización para tratar
TREATMENT AUTHORIZATION-PRV
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Templeton Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Thousand Oaks Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
Vista Clinic
Forms
TREATMENT
AUTHORIZATION
Autorización para tratar
TREATMENT
AUTHORIZATION
Fill out /Print
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
EMPLOYER
SET UP FORM
Formulario de configuración del empleador.
Fill out /Print
Workplace Notices
IN CASE of INJURY
WALL SIGN
IN CASE of INJURY
WALL SIGN
Fill out /Print
For more information, please contact us at info@akesomedical.com