Authorization Form for Examination / Treatment

Authorization Form 10-2023

Company Name Employee Name OccuMed Location Date of Injury Time of Injury Light Duty Available Follow client protocols on file Asbestos Examination Audiogram Blood Test CBC SMAC DOT Medical Examination (Re-Certification) DOT Medical Examination (New Certification) Functional Capacity Evaluation Job Placement Assessment Pre-Placement Medical Examination Pulmonary Function Test (PFT) Respirator Certification Examination Respirator Questionnaire Return-to-Duty/Work Examination Respirator Fit Test X-ray Post Accident Pre-Placement Random Screen Return-to-Duty Follow Up Reasonable Suspicion Instant Drug Screen (5-Panel) Instant Drug Screen (10-Panel) eScreen Lab Breath Alcohol Test (BAT) Saliva Swab Urine Drug Screen (DOT) Urine Drug Screen (Non-DOT) Hair Analysis Blood Alcohol Tetanus/TDAP Rabies Influenza Hep A Hep B Hepatitis Titer TB Varicella Other Special Instructions Approved By Date Phone

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