Employer Authorization Form — Midtown Occupational Health

Employers, please use the form below to authorize Midtown Occupational Health to provide services to your employee. This form is required before we can perform any occupational health services.

If you prefer, you can also download and complete a paper version:

• Download Employer Authorization Form (English)
• Download Employer Authorization Form (Spanish)

Digital Employer Authorization Form

Please complete all required fields below:

If you have any questions about completing the Employer Authorization Form, please Contact Us and our team will be happy to assist you.