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Employer Authorization Form
Authorization for Occupational Health Services
ALL services included in account profile for respective services WILL be performed unless otherwise stated.
Employer/Company
Company Address
Employee or Prospective Employee Name
Company representatitve authorizing service
Phone
DRUG AND ALCOHOL SCREENING:
Regulated Drug Screen
Non-Regulated Drug Screen
Instant Non-Regulated UDS
ESCREEN E-Cup
Collection Only Urine Drug Screen (employer must provide CCF)
MUST Drug Screen
Breath Alcohol Test
Hair Collection
Nicotine Instant Screening
Court Ordered Panel w/ Etg
Reason for test
Pre-Placement
Random
Reasonable Suspicion
Follow-Up
Return to duty
VACCINATIONS AND LABORATORY SERVICES:
PPD
PPD 2 Step
TDAP
Hepatitis B Series
Titers
Urinalysis
Glucose Testing
Influenza
BMI Testing
PHYSICAL EXAMINATIONS AND OSHA COMPLIANT SERVICES:
Pre-Placement Exam
Return to Work Exam
Fit for Duty Exam
DOT Exam
Hazard Surveillance
Baseline/Periodic
Respirator Exam
Audiogram
OSHA Resp. Questionnaire
Pulmonary Function Test
QUANTITATIVE Respirator Fit Test
QUALITATIVE Respirator Fit Test
By signing this authorization, the said employer acknowledges full responsibility for payment for ALL services related to examinations, screening, diagnostic testing and treatment and or medications deemed necessary by the treating Physician for the authorized individual named in this form unless it is previously requested to collect payment at time of service from the individual. It is understood that services will be paid in full upon receipt of billing for all amounts due. It is also understood that the employer will be responsible for payment of all services related to injury or illness care of the employee if said case is determined work related or not, or if the claim is denied by the workers' compensation insurance carrier.
Signature of Authorization
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Email
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