Patient Forms and Identification

This page provides key forms and guidelines for patient identification that you will need for treatment at a Concentra Medical Center.

• Patient Information Form – You need to complete and sign this form, which will be permanently filed in your chart. This form – available for both work-related and non-work-related injuries or illnesses – may be printed and completed in advance, or a copy will be available when you check in. See form links in sidebar.
• Patient Authorization Form – If you’re seeking treatment for urgent care (a non-work-related injury or illness), you will need to sign a form that authorizes Concentra to provide services. It will also be permanently filed in your chart. This form may be printed and completed in advance, or a copy will be available when you check in. See form links in sidebar.
• Photo Identification – Before treatment you must show us valid photo identification, which can be a driver’s license, passport, military ID, employment badge, or student identification card. Your photo identification will be copied and kept on file. Please call the center if you have questions about other forms of identification.
• Treating Minor Age Patients – Patients under the age of 18 must be accompanied by a parent or legal guardian. If the minor is not accompanied by a parent or legal guardian, the accompanying adult must have a notarized statement signed by the parent/guardian and authorizing treatment. The parent/guardian/adult will be asked for photo identification, current insurance, and (as required) proof of guardianship. This information will be copied and kept in the minor's file.
• Insurance for Urgent Care – If your injury or illness is non-work-related and you have insurance, you must also bring your current insurance card. Your proof of insurance will be copied and kept on file.

HIPAA Information

We know that you want to be assured that your individually identifiable health information will be safeguarded. Concentra makes all reasonable efforts to comply with HIPAA – the Health Insurance Portability and Accountability Act of 1996 – and privacy regulations. We take these matters very seriously and have instituted numerous internal and external measures to maximize compliance.

When you sign your Patient Authorization Form, you are acknowledging awareness of Concentra’s HIPAA policies and that you have seen our Notice of Privacy statement. This statement may be printed and reviewed in advance, or a copy will be available when you check in.

Learn more about Concentra's HIPAA and privacy program. »

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