Scan this barcode into eScreen123®

*AI319447744H*
AI319447744H

Instructions for Kristina Robinson

WALK IN APPOINTMENT - COMPLETE BY • You are required to take a photo ID,

11/14/2019 - SEE "Additional Notes" this ePassport, and all documents with
which it printed.

• If you are under 18, a parent or legal

Note: Completion time displayed does not mean that the guardian may be required in order for
service provider is open until the time shown.
services to be performed. Verify with
the service provider before arriving.
Please proceed to the following location:
EmergiCare Inc
4117 N ELIZABETH
PUEBLO, CO 81008

Phone: 719-545-0788 Fax: 719-545-0787

Note: Please call service provider for operational hours and to schedule an
appointment or visit the service provider’s website for hours of operation.

Additional Notes: WALK IN BY 2PM

Instructions for Service Provider

Providers with eScreen123 must scan ePassport into eScreen123. Use eScreen Scheduled Event Account.
Bill services to: eScreen, Inc., PO Box 25902, Regulation: NON-DOT
Overland Park, KS 66225 Reason for Test: Pre-employment
Services(1): 1. Urine Collection - 1369 -
7DSP/EXP
Account: 105226-203 OPI2000/AMP500/COC150/ECS/6
Maxim Hlth Srvcs SW550203 AM/PHN (1369)
Account Type: National Account
Reason for Service: Pre-employment
Services(1): 1. TB/PPD Skin Test- 1 step only
Participant ID:

© 2019 Abbott. All rights reserved. All trademarks referenced are trademarks of either the Abbott group of companies or their
respective owners.
Clinic #: 1412 eScreen Account #: 105226-203 Confirmation AI319447744H

AI319447744H
Applicant/Employee Name: Robinson, Kristina
Confirmation Number: AI319447744H
eScreen Account Info: 105226-203 AI319447744H
eScreen Site ID: 1412 - EmergiCare Inc
Please Note: The information on this document is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this information only for the applicant referenced above.

Instructions:

Take all documents that print with this packet of information to the clinic.

Medical Services:

1. TB/PPD Skin Test- 1 step only :
TB TEST MUST BE READ WITHIN THE 48-72
HOUR TIME FRAME FOLLOWING THE
INJECTION. PLEASE MAKE NOTE OF THE
EXACT TIME THE INJECTION WAS GIVEN AND
DO NOT RETURN UNTIL IT HAS BEEN A
MINIMUM OF 48 HOURS. THIS WINDOW OF
TIME IS SPECIFIC - EVEN ONE MINUTE BEFORE
OR AFTER THE 48-72 HOURS WILL CAUSE AN
INVALID RESULT AND THE TEST WILL HAVE
TO BE REPEATED.
Clinic #: 1412 eScreen Account #: 105226-203 Confirmation #: AI319447744H

AI319447744H
Applicant/Employee Name: Robinson, Kristina
Confirmation Number: AI319447744H
eScreen Account Info: 105226-203 AI319447744H
eScreen Site ID: 1412 - EmergiCare Inc
Please Note: The information on this document is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this information only for the applicant referenced above.

Clinic Instructions:
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123
software.

This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed.
Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For
paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the
eScreen123 Follow-Up tab or fax completed documents to 913-577-2149. Please fax ORIGINAL FORMS ONLY.
Copies/carbons/scanned images/highlights are often illegible upon receipt.

Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be
reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly.

Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the
instructions.

If any occupational health service(s) are requested in addition to the services listed, please call 800-881-0722 Ext: 3015 for
approval/direction.

Please follow standard protocol unless specified for the services listed below.

[] TB/PPD Skin Test- 1 step only - This service can be performed in eScreen123. When performing electronically,
please ensure you return to eScreen123 to complete the TB test read, upon donor's return to the clinic. TB test
MUST be read within the 48-72 hour time frame. If the patient returns before 48 hours please instruct them to
wait or come back after it has been a minimum of 48 hours from the time of injection. The 48-72 hour time frame
is exact - even one minute before or after will be marked as an invalid result.

Clinic Instructions Page 1 Of 2

 AI319447744H
Applicant/Employee Name: Robinson, Kristina
Confirmation Number: AI319447744H
eScreen Account Info: 105226-203 AI319447744H
eScreen Site ID: 1412 - EmergiCare Inc
Please Note: The information on this document is specific to a single event. To ensure timely and accurate
reimbursement for the services, please use this information only for the applicant referenced above.

Clinic Instructions:
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123
software.

This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed.
Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For
paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the
eScreen123 Follow-Up tab or fax completed documents to 913-577-2149. Please fax ORIGINAL FORMS ONLY.
Copies/carbons/scanned images/highlights are often illegible upon receipt.

Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be
reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly.

Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the
instructions.

If any occupational health service(s) are requested in addition to the services listed, please call 800-881-0722 Ext: 3015 for
approval/direction.

Please follow standard protocol unless specified for the services listed below.

BILLING INFORMATION:
Invoices for services must include the eScreen account information and SSN/ID or confirmation number (as
listed above) for the patient. Direct all invoices to eScreen at:
eScreen, Inc.
Attn: Accounts Payable
PO Box 25902
Overland Park, KS 66225-5902

Incomplete medical service forms will not be reported, and the reimbursement will not be issued until
all required information has been received by eScreen.
If you have any questions, please contact eScreen at 800-881-0722 Ext: 3015

Clinic Instructions Page 2 Of 2