All online inquiry forms will be unavailable from 7 p.m. CT on May 7 through 10 p.m. CT on May 12 due to system maintenance. Responses will be slower than usual during this time.
forms for patients and employers
Concentra is Going Paperless – A Smarter, Greener Way to Care
Concentra is transitioning to paperless forms across all medical centers. By digitizing our forms, patients can check in faster and more easily, reducing wait times and minimizing the need for printed paperwork. Whether visiting us for occupational health services or urgent care, our new digital process ensures a more efficient and eco-friendly experience from start to finish.
For existing customers, we encourage you to use the Concentra HUB to authorize patient visits and access electronic intake form links. Concentra HUB is a fully integrated occupational health platform that provides 24/7 access to authorization forms and more. Employees should complete intake forms online prior to their visit.
Forms for New Customers and Patients
New Customer Forms
For new Concentra customers who do not yet have a HUB account, the necessary forms can be found below.
- Employer Authorization Form (PDF,161 KB) — We require a completed and signed Employer Authorization Form for any patient visiting a Concentra medical center for initial treatment of a new injury or other occupational health service, such as physical exams.
- Telemedicine Digital Authorization - By filling out this form, you authorize your employee for telemedicine. After you complete the form, it will be automatically sent to Concentra. This form must be completed every time an employee uses Concentra Telemed.
- Request for Medical Surveillance Services (PDF,101 KB) — Employers interested in Medical Surveillance Exams from Concentra can complete this form in preparation for a discussion with one of our experts.
- Regulatory Exam Authorization Form (PDF,578 KB) — Employers authorizing regulatory exams, such as Respirator Clearance and Medical Surveillance, may complete the attached form and send it in with the employee to provide essential details of the employee’s exposures and work environment to the clinician. This form is especially helpful to provide best-in-class care for new customers.
Patient Forms
Most standard government forms are available in a digital format. For those that are not, we offer downloadable options. These should be printed and filled out prior to arriving at one of our many Concentra medical centers.
- Travel Health Questionnaire (PDF, 1,325 KB) – Every travel health patient obtaining a travel health consult must provide their travel itinerary, health and vaccine history prior to their consultation. Please print and complete this form prior to your visit.
- Insulin-treated Diabetes Mellitus Assessment MCSA-5870 (PDF,255 KB) — Commercial drivers with insulin-treated diabetes need to have this form completed by their treating clinician no more than 45 days prior to examination by a certified medical examiner (CME). This form is required before a Medical Examiner's Certificate Form MCSA-5876 can be issued to a certified driver.
- Vision evaluation report Commercial drivers with “monocular vision,” as defined by the FMCSA, or who do not meet FMCSA’s vision standard at a physical qualification examination must have this form completed by an ophthalmologist or optometrist no more than 45 calendar days prior to examination by a certified medical examiner (CME). This form is required before a Medical Examiner’s Certificate Form MCSA-5876 can be issued to a certified driver.