Appointment Now

704 360 8893

Worker Compensation Authorisation

  • Demographic/
    General Information

    1
  • Insurance
    Information

    2
  • Responsible
    Party

    3
  • Worker Compensation
    Authorisation

    4

Worker Compensation Authorisation

Employer’s Name *
Phone *
Address *
City
State
Zip
WC Carrier
Phone
Claim No
Address
City
State
Zip
Date of Injury
Employer Contact
Drug Screen Required?
Patient Signature *
Agreement Statement *
I clearly understand and agree that all services rendered to me will be charged directly to me in the event that worker’s Compensation Benefits are denied.

We Are Accepting New Patients

If you have any questions, concerns, or comments regarding Eastway Medical Clinic & Urgent Care. You can either call us at 704 360 8893 or send us an email to info@eastwaymedicalclinic.com

We’re here for you

Eastway Medical Clinic & Urgent Care 1220 Eastway Drive Charlotte, NC 28205

Phone: 704 360 8893

Fax: 704 626 6515

hours of operation

Monday

8:30 am – 5:30 pm

Tuesday

8:30 am – 5:30 pm

Wednesday

8:30 am – 5:30 pm

Thursday

8:30 am – 5:30 pm

Friday

8:30 am – 5:30 pm

Saturday

9:00 am – 3:00 pm

Sunday

Closed

Get Socials

Link with us via your social networks: