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Medical Authorization
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Medical Authorization
Employee Name
(Required)
First
Last
Hidden
Employee Email Address
If email address is entered, employee will receive notification with instructions and address for Work Health Solutions
Company
(Required)
Company Contact Name
(Required)
Company Contact Phone Number
(Required)
Company Contact Email Address
(Required)
Reason for Visit: Please select only one
(Required)
Workers' Compensation Injury Treatment
Pre-Employment Services
Surveillance Testing (Audiogram, Respiratory, etc.)
Substance Abuse Testing ONLY (Post Accident, Random, Reasonable Suspicion, Cause, Follow-Up, Return to Duty)
Fitness for Duty Exam (Job Description Required)
Return to Work Exam (Medical Records and Job Description Required)
DOT Exam Recertification
COVID Testing
Medical Record Evaluation
Independent Medical Examination (IME)
Other
If "other", please specify:
Post Injury Substance Abuse Testing (Not Required):
Drug Testing per company protocol
Breath Alcohol per company protocol
Send Bill to:
(Required)
Billing per Employer Protocol
Work Comp Insurance
Reason for Testing:
(Required)
Pre-Placement / Employment / New Hire
Post Accident
Random
Reasonable Suspicion/Cause
Return to Duty
Follow-Up
Other (Specify)
Physical Exam:
DOT
Non-DOT
Silica
Other
Physical Abilities Test/ Job Function Test:
Pre-Placement
Fit for Duty
Lift Test (Per Company Protocol)
If "other", please specify:
If "other", please specify:
Substance Abuse Testing:
WHS - 5 Panel Rapid Minus THC (Non - DOT)
WHS - 5 Panel Rapid (Non - DOT)
WHS - 10 Panel Rapid Minus THC (Non - DOT)
WHS - 10 Panel Rapid (Non - DOT)
WHS - 10 Panel + Fentanyl - Lab Based (Non - DOT)
Non-DOT - Collection Only (Company Chain of Custody)
WHS DOT Drug Screen (Work Health Solutions Chain of Custody)
DOT- Collection Only (Company Chain of Custody)
WHS Hair Test (5 panel) - (Work Health Solutions Chain of Custody)
Hair Collection Only (Company Chain of Custody)
Breath Alcohol Testing - NON - DOT
Breath Alcohol Testing - DOT
Drug Screen Observation/Witness Collection:
Yes
No
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DISA: If you do not know what DISA stands for, please do not complete this section
Pre-Placement
Random
Post - Accident
Hair
Urine (Non - DOT)
Urine (DOT)
BAT (Non-DOT)
BAT (DOT)
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT Agency
(Required)
FMCSA
FAA
FRA
FTA
PHMSA
USCG
Respiratory Services:
Fit Testing - Quantitative (Quantifit2)
Fit Testing - Qualitative (Taste Test)
Pulmonary Function Testing (PFT)
OSHA Questionnaire
Masks:
(Required)
3M Half Facepiece 6000 series
3M Half Facepiece 7000 series
MSA Half Facepiece
3M Full Facepiece Respirator
Scotts Full Facepiece Respirator AV 2000
North™ Series Full-Facepiece Respirator
Other
If other, please specify:
(Required)
Masks:
(Required)
3M Half Facepiece 6000 series
3M Half Facepiece 7000 series
MSA Half Facepiece
N95/KN95
Other
If other, please specify:
(Required)
Additional Services:
Vision Testing
TB Skin Test (Employee must be able to return to the clinic within 48 to 72 hours to have test read)
Heplisav B Injection
Audiogram
2 View L-Spine Xray
Vision Testing
(Required)
Titmus (Near, Distant and Peripheral)
Ishihara (color)
Jaeger (Near Vision Acuity)
Peripheral
Snellen (Distant Vision)
Depth Perception
Audiogram
(Required)
Baseline
Retest
Make-up Test
Annual Test
Laboratory Tests (Please be specific):
COVID - 19 Testing
Rapid Antigen Test
PCR Lab Test
CUE Test
Other Requirements (Please be specific):
Authorized Signature (Please Type Full Name)
(Required)
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