Telemedicine Authorization

Employees of registered companies now have access to 24/7 care through Agile's Telemedicine program.
Please register an injured or ill emloyee by filling out the form below.

 

ONLY FILL OUT THIS FORM AS DIRECTED BY YOUR SUPERVISOR

 

 

Instructions

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  • Complete this Telemedicine Treatment Authorization form and click “Submit Form” at the bottom.
  • Contact Agile Occupational Medicine at (424) 292-3260 during normal business hours Monday-Friday 8:30AM – 5:30PM, to complete theregistration process and initiate.
  • After hours, call 888-84TELEMED (888-848-3536) to speak with the on-call physician to complete theregistration process and initiate the telemedicine visit.
  • Click on the link sent to the patient’s email or cell phone or from the designated email or cell phone.
  • Enter name and date of birth to confirm identity and then securely connect to an occupational medicine doctor.
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Registration Assistance

If an injury is a life-threatening emergency, please dial 911 or send the injured worker to your local emergency room or hospital.  

Paper Registration

If a supervisor referring an employee for a telemedicine appointment prefers filling out a paper/PDF form please click below to download.