Scribd Logo
Upload

Welcome to Scribd!

  • Request For Service Fillable

    Uploaded by

    Zachary Curtis
    3 views1 page
    This document is a request form for occupational health services and treatment authorization. It requests information about the employee such as name, date of birth, and employer. It lists various medical services and tests that may be requested such as drug and alcohol testing, immunizations, physical exams, and functional testing. The form provides instructions for the employee regarding bringing the form and ID to appointments and notes on clothing for functional testing. It also lists the locations and hours of Asante Work Health.

    Original Description:

    Original Title

    Request-for-service-fillable

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document
    This document is a request form for occupational health services and treatment authorization. It requests information about the employee such as name, date of birth, and employer. It lists various medical services and tests that may be requested such as drug and alcohol testing, immunizations, physical exams, and functional testing. The form provides instructions for the employee regarding bringing the form and ID to appointments and notes on clothing for functional testing. It also lists the locations and hours of Asante Work Health.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    3 views1 page

    Request For Service Fillable

    Uploaded by

    Zachary Curtis
    This document is a request form for occupational health services and treatment authorization. It requests information about the employee such as name, date of birth, and employer. It lists various medical services and tests that may be requested such as drug and alcohol testing, immunizations, physical exams, and functional testing. The form provides instructions for the employee regarding bringing the form and ID to appointments and notes on clothing for functional testing. It also lists the locations and hours of Asante Work Health.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Request for Services / Treatment Authorization

    Employee/patient: ____________________________________________________________________________________________ Date of birth: ________________________________

    Employer: ___________________________________________________________________________________________________________Phone: __________________________________________


    Form completed by: Employer: Name/phone______________________________________________________________________________________________________________
    Asante staff: Initials _________________________

    Please send this form with the employee/applicant. Fax to (541) 789-5965 or email workhealth@asante.org.

    Drug testing Breath alcohol testing (BAT) Labs – titers Injections

    DOT Non-DOT DOT Non-DOT Other:______________________________ Other: _________________________________

    Pre-employment Pre-employment Hep B antibody Tetanus


    Random Random Varicella antibody MMR
    Post-accident Post-accident MMR Hep B
    Reasonable suspicion Reasonable suspicion PPD
    Follow-up Follow-up
    Return to duty Return to duty

    Notes: _________________________________________________________________________________________________________________________________________________________________________________________

    Other services
    CXR Resp. fit test Audio OSHA/Non-OSHA

    DOT physical exams Non-DOT physical exams


    Standard Comprehensive (with Audio & PFT) Standard Comprehensive (with audio & PFT)
    Pre-employment CDL Pre-employment
    Recert. CDL Fit for duty
    Non-CDL driver Asbestos
    RFT qualifying physical

    Appointment date: ______________________________________________________________________________________________Time: ______________________________________


    Functional testing job title: _______________________________________________ Appointment date: ________________________Time: _____________________

    Employee instructions:
    1. You must bring this form to your appointment(s).
    2. You must bring photo ID. Please arrive 15 minutes early to complete registration and paperwork.
    3. Please do not bring children with you.
    If you are scheduled for a functional test:
    • Wear closed-toe shoes with good support. No sandals or high heels (preferably shoes that tie).
    • Wear comfortable, loose-fitting clothing that will allow you to move freely.
    • Do not drink any caffeine products on the day of the evaluation (coffee, tea, cola, chocolate, etc.).
    • Report all medications currently being taken at the time of evaluation. Some may affect your heart rate and must
    be taken into consideration with the results.

    ASANTE WORK HEALTH LOCATION AND HOURS


    781 Black Oak Drive, Suite 102, Medford, OR 97504 (541) 789-4236 ■ Monday–Friday, 7 a.m. to 4:30 p.m.
    625 SW Ramsey, Suite A, Grants Pass, OR 97527 (541) 507-2290 ■ Monday–Friday, 7:30 a.m. to 4:30 p.m.
    2841 Ave G, Suite 300 White City, OR 97503 (541) 789-2273 ■ Monday–Friday, 8 a.m. to 4:30 p.m.

    J/forms/occ health/request for services (06/28/2022)

    You might also like