Authorization for Testing
Testing Location
*
Please Select
BHP Sulphur Clinic - 3649 S. Beglis Pkwy, Sulphur, LA
BHP Lake Charles Clinic - 4150 Nelson Rd. Building B Suite 5, Lake Charles, LA
BHP DeRidder, Louisiana - 301 S Washington St. Suite B, DeRidder, LA
BHP Leesville Clinic - 931 Verone Terrace, Leesville, LA
BHP Nederland Clinic - 1005 Nederland Ave, Nederland, TX
BHP Deer Park Clinic - 5003 College Park Dr, Deer Park, TX
BHP McAllen Clinic - 422 E. Dove Ave, McAllen, TX
BHP Corpus Christi Clinic - 7406 Up River Rd. Corpus Christi, TX
BHP Brand Clinic
GCOM Main Clinic - 15389 Airline Hwy, Baton Rouge
GCOM Gonzales Safety Council - 1205 W. Edenborne Pkwy, Gonzales
GCOM Baton Rouge Safety Council - 10099 N. Reiger Rd, Batoun Rouge
GCOM Addis Safety Council - 7640 Highway 1, Addis
GCOM Reserve Clinic - 3919 W. Airline Hwy, Reserve
GCOM Walker Safety Council - 29756 Walker South Rd, Walker
GCOM Geismar Clinic - 6105 Highway 73, Geismar
Company Information
Company Name
*
Requested By:
*
First & Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Testing Information
Employee Name
*
First & Last Name
Date of Birth
-
Month
-
Day
Year
SS#
*
Date of Testing
*
-
Month
-
Day
Year
Date
PO#
Position
Reason for Testing
*
Please Select
Pre-Employment
Pre-Access
Annual
Random
Post-Accident
Return to Work
Reasonable Suspicion
Follow-Up
Return to Duty
Other
Requested Testing
Check All That Apply
Services Requested
*
Physical Exam
Drug Testing
Alcohol Testing
DISA/ASAP Testing
FCE
Respiratory and Fit Test
Audio Testing
Vision Testing
Lab Test and X-Rays
Other Medical Services
Physical Examinations:
*
Asbestos - Physical, PFT, B-Reader
HAZMAT - Physical, PFT, Chest X-ray, CBC/CMP
Silica - Physical, PFT, B-Reader, TB Test - Skin
Silica - Physical, PFT, B-Reader, TB Test - Blood work
DOT Physical
Coast Guard Physical
Fit For Duty Physical
Crane Operator Physical
Return to Work Physical
Basic Physical
Other
Drug Test
*
Quick Test
Non-DOT Drug Screen (BHP Lab)
Non-DOT Collection (Chain of Custody Provided)
DOT Drug Screen (BHP Lab)
DOT Collection (Chain of Custody Provided)
Oral Fluid Drug Screen (BHP Lab)
Oral Fluid Drug Screen Collection (Chain of Custody Provided)
Hair Drug Screen (BHP Lab)
Hair Drug Screen Collection (Chain of Custody Provided)
Quick Test
*
5 Panel
10 Panel
12 Panel
Non-DOT Drug Screen Panel
Enter Panel Number
DOT Drug Screen (BHP Lab) Agency
*
FMCSA
PHMSA
FTA
FAA
FRA
USCG
DOT Drug Screen (Chain of Custody Provided) Agency
*
FMCSA
PHMSA
FTA
FAA
FRA
USCG
Observed Collection?
No
Yes
CDL#
Alcohol Testing
*
Non-DOT Breath
Non-DOT Saliva
DOT Breath
DISA Drug Test
DOT Urine Drug Screen
DCCHA Urine Drug Screen
DCCOF Oral Fluid Drug Screen
DCCHT Hair Test
NASAP Urine Drug Screen
Other
ASAP Drug Test
ASAPCC Drug Screen
NASAP Drug Screen
LACC Drug Screen
Other
DISA Alcohol
Non-DOT Breath Alcohol Test
Non-DOT Saliva Alcohol Test
DOT Breath Alcohol Test
ASAP Alcohol
ASAPCC Alcohol Test
NASAP Alcohol Test
LACC Alcohol Test
FormFox also submitted?
*
Yes
No
FormFox Test Code
Observed Specimen?
Yes
No
Respiratory Testing
*
OSHA Respirator Questionnaire
Pulmonary Function Test (PFT)
1/2 Face
Full Face
Full Face Mask:
*
1/2 Face Mask:
*
Audio Testing
*
Baseline
Comparison
Re-test
Vision Testing
*
Ishihara
Jaegar
Titmus
Lab Test
CMP/CBC/Liver
CBC
Urinalysis
Blood Lead / ZPP
Urine Phenol
Blood Benzene
Hemoccult
HIV
RPR/VDRL
TB Skin
TB Gold - bloodwork
Other
X-Rays
Chest X-Ray
Lumbar X-Ray
Chest X-Ray Views
*
1
2
1 view b-reader
Lumbar X-Ray Views
*
2
3
5
Other Medical Services
EKG
Other
Immunization
Additional Information for Clinic:
Submit
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