AUTHORIZATION REQUEST FOR ADDITIONAL CHIROPRACTIC TREATMENT PLEASE TYPE OR PRINT AND PROVIDE ALL OF THE Claim Number INFORMATION REQUESTED REQUEST FOR ADDITIONAL CHIROPRACTIC TREATMENT Name of Injured Employee SSN # Date of Injury Name of Employer Name of Treating Chiropractor Date of Last Treatment Number of Treatments Since Injureds First VisitDESCRIBE 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: Give the Date By Which the Treatment Will Be Completed If Authorization is Granted: Is the Injured Employee If "NO" Estimate the Capable of Working Now? Date By Which The Employee [ ] YES [ ] NO Will Be Able To Return To Work: Date Signature and Address of Treating Chiropractic Physician Telephone Number D.C. FOR INSURERS ACTION [ ] AUTHORIZATION IS GRANTED FOR [ ] Authorization for Additional Chiropractic ADDITIONAL CHIROPRACTIC TREATMENTS. Treatment is Denied [ ] Other Action: Date Signature Title D-32 (rev. 7/99)