Authorize to Treat - Holland Medi-Center

Company / Organization Name*

Company / Organization Phone*

Authorized By Name*

Authorizer Phone*

Submitter Email*

Employee Information

Employee Name*

First Last

Employee Date of Birth

Employee Phone*

Employee Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

INJURY

Treatment/Evaluation

Drug Screen with initial visit

Breath Alcohol Test

DOT Procedures

Physical Examination

Drug Test - Federally Mandated

Reason For Drug Test

DOT - Specify DOT Agency

Alcohol Test - Federally Mandated

Reason For Alcohol Test

Non-DOT Procedures

Physical Examination

Drug Test - Type

Drug Test Protocol*

Reason For Drug Test

Alcohol Test - Type

Reason For Alcohol Test

Other

Other test options

Labs

Lab details*

Hepatitis B Vaccine

Vaccine Number*

Tuberculosis (TB)

TB Testing Options*

1 Step
2 Step

Titer

Titer Type*

Lift test & education

Number*

Other Instructions

Company instructions: Other testing and/or company specific instructions

Name

This field is for validation purposes and should be left unchanged.

HOLLAND MEDI CENTER

AUTHORIZE TO TREAT FORM

Employee Information

INJURY

DOT Procedures

Non-DOT Procedures

Other

Client Login

Authorize to Treat Form