Employer Authorization Form

Please indicate which clinic you will

be using for employer services.
(clinic)

Company Details Date: Employee Details:

Company Name: Patient Name:

Authorizing Contact: DOB:

Phone #: *Employee must present photo ID at time

Email: of visit unless accompanied by escort.

Authorization Category Work Comp

O Pre-Employment O Work Comp O Treatment Only O Drug Screen - Mark Below
O Post Accident O Random Date of Injury
O Annual/Periodic O Follow-up
Injured Body Part
O Reasonable Suspicion
Insurance Carrier

O OBSERVED Claim Number

Drug Screen Selections

O DOT - With Our MRO O NON-DOT - Collection Only O Hair Follicle
O DOT - Collection Only O Rapid 5 Panel O Saliva
O NON-DOT 5 Panel - With our MRO O Rapid 10 Panel O Breath Alcohol - DOT
O NON-DOT 10 Panel - With our MRO O Cotinine O Breath Alcohol - NON-DOT
Pre-Employment / Random Work Comp / Post Accident / Reasonable Suspicion
**URINE DRUG SCREEN CUTOFF TIMES** STOP 2 HOURS BEFORE CLOSING ANYTIME DURING OPEN HOURS

Physicals Other Services

O Basic Pre-Employment O Audiogram O EKG

O Agility/POPAT O TB Test O PFT
O Respirator/Clearance O Titers O Hepatitis (A) /(B)
O DOT New O Fit Test O Chest X-Ray
O DOT Recertification O Other
O Return-to-Work
O Other
COVID-19 Testing
O PCR (24hr) O Rapid-PCR O Rapid Antigen

Billing Information: Notes/Concerns:

PLEASE SCAN OR VISIT LINK TO COMPLETE ONLINE
BILLING INFO IF

- You are a new client and have NOT

created an account with us before.

- You are an existing client and have

updated billing information.
https://bit.ly/31vQN8Y