(Patient must present Authorization and Photo ID
at the time of service)
FORM C - Authorization for Examination or Treatment
Patient Name
First Name
Last Name
Social Security Number
Employer
Date of Birth
/
Month
/
Day
Year
Date
Street Address
Location Number
Work Related
Injury
Illness
Unknown
Physical Examination
Preplacement
Baseline
Annual
Exit
DOI Reported
* Substance Abuse Testing (check all that apply)
Regulated drug screen
Breath alcohol
Hair collect
Rapid drug screen
Collection only
Non-regulated drug screen
Other
Type of Substance Abuse Testing
Preplacement
Post-accident
Follow-up
Reasonable cause
Random
DOT Physical Examination
Preplacement
Recertification
Special Examination
Asbestos
Respirator
Audiogram
* Human Performance Evaluation
HAZMAT
Medical Surveillance
Other
Billing (check if applicable)
Employer to pay charges on Evaluation Only
Authorized by
First Name
Last Name
Title
Phone
Format: (000) 000-0000.
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: