Authorization-to-Treat

September

06

2010

335 N. 120th Avenue • Holland, MI 49424 • Phone: 616.392.5222 • Fax: 616.392.3653
Copyright © 2005-2008. Holland Medi Center

	Items followed by (*) are required fields.
Company (*)	Please type your company name.
Person Authorizing Treatment (*)	Name of person authorizing treatment.
Position
Employee (*)	Please type your full name.
Phone (*)	Please type your phone number.
	WORKERS COMPENSATION
Date of Injury	MM/DD/YYYY
Check one	Injury treatment only Drug screen Evidential breath test
Area/type of injury
Brief comment	Invalid Input
	PRE-PLACEMENT
Position applying for
Sub Type
Check all that apply	Audiogram Titmus Vision Back Exam Lift Test
	X-RAY
Lumbar	AP & Lateral LSS Invalid Input
Check if applies	Chest Invalid Input
Specific Details
	ADDITIONAL TESTS
Check all that apply	Resp. Questionnaire Respirator Physical Pulmonary Function Test Hepatitis B Series Hepatitis B Titer Fit Test TB Psyllium Latex Asbestos HazMat Lead Tetanus Invalid Input
Specific Details
Physical Details	General DOT DOE Invalid Input
Specific Details
Brief comment	Invalid Input
	SUBSTANCE SCREENING (Picture ID required)
Drug Panels	5 8 10 Invalid Input
DrugPanelsB	Collection Only Evidential Breath Alcohol
Reason for screening	Pre-Placement Random Reasonable Suspicion Incident/Near Miss Invalid Input
	IMMUNIZATIONS
Immunizations	TB Hepatitis B Series Hepatitis B Titer Tetanus
Specific
	DEPT. OF TRANSPORTATION (Picture ID required)
DOT Physical	New Certification Re-Certification
DOTCheckbox	DOT Drug Screen DOT Evidential Breath Test
Reason for screening	Pre-Placement Post-Accident Random Incident/Near Miss Invalid Input
	ANNUAL MEDICAL SURVEILLANCE
Checkbox4	Respiratory HazMat Lead Asbestos Audiogram Chemical Heavy Metals
Specific
Additional Info	Invalid Input

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