HOLLAND MEDI CENTER AUTHORIZE TO TREAT FORM Printable Authorize to Treat Form Company / Organization Name* Company / Organization Phone*Authorized By Name* Authorizer Phone*Submitter Email* Employee InformationEmployee Name* First Last Employee Date of Birth MM slash DD slash YYYY Employee Phone*Employee Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country INJURYTreatment/Evaluation Drug Screen with initial visit Breath Alcohol Test DOT ProceduresPhysical ExaminationSelect OneNewRecertificationFollow-upDrug Test - Federally MandatedSelect OneUrineReason For Drug TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upDOT - Specify DOT AgencySelect OneFMCSAFTAFAAPHMSAFRAUSCGAlcohol Test - Federally MandatedSelect OneBreath Alcohol TestReason For Alcohol TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upNon-DOT ProceduresPhysical ExaminationSelect OnePost Offer/Pre-employmentReturn to WorkFit for DutyRespiratoryHazmatAsbestosOtherDrug Test - Type Pre-established Protocol (HMC Clients) Test @ HMC-rapid screen Collection ONLY-Urine Hair Collection Saliva Direct Observe Drug Test Protocol*Select One610NicotineReason For Drug TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upAlcohol Test - TypeSelect OneBreath Alcohol TestReason For Alcohol TestSelect OnePre-employmentRandomReasonable Suspicion/CausePost AccidentReturn to WorkFollow-upOtherOther test options Chest X-Ray Pulmonary Function Test Audiogram baseline Vision Titmus Respirator Fit Test Tetanus Audio Annual Vision Ishahara Audio Follow-up Vision Jaeger 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 InstructionsCompany instructions: Other testing and/or company specific instructionsCommentsThis field is for validation purposes and should be left unchanged.
