BHP Authorization

Authorization for Testing
Testing Location*
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

MonthDayYear
SS#*
Date of Testing*

MonthDayYear
Date
PO#
Position
Reason for Testing*
Requested Testing

Check All That Apply
Services Requested*

Physical ExamDrug TestingAlcohol TestingDISA/ASAP TestingFCERespiratory and Fit TestAudio TestingVision TestingLab Test and X-RaysOther Medical Services
Physical Examinations:*

Asbestos - Physical, PFT, B-ReaderHAZMAT - Physical, PFT, Chest X-ray, CBC/CMPSilica - Physical, PFT, B-Reader, TB Test - SkinSilica - Physical, PFT, B-Reader, TB Test - Blood workDOT PhysicalCoast Guard PhysicalFit For Duty PhysicalCrane Operator PhysicalReturn to Work PhysicalBasic PhysicalOther
Drug Test*

Quick TestNon-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 Panel10 Panel12 Panel
Non-DOT Drug Screen Panel
Enter Panel Number
DOT Drug Screen (BHP Lab) Agency*

FMCSAPHMSAFTAFAAFRAUSCG
DOT Drug Screen (Chain of Custody Provided) Agency*

FMCSAPHMSAFTAFAAFRAUSCG
Observed Collection?

NoYes
CDL#
Alcohol Testing*

Non-DOT BreathNon-DOT SalivaDOT Breath
DISA Drug Test

DOT Urine Drug ScreenDCCHA Urine Drug ScreenDCCOF Oral Fluid Drug ScreenDCCHT Hair TestNASAP Urine Drug ScreenOther
ASAP Drug Test

ASAPCC Drug ScreenNASAP Drug ScreenLACC Drug ScreenOther
DISA Alcohol

Non-DOT Breath Alcohol TestNon-DOT Saliva Alcohol TestDOT Breath Alcohol Test
ASAP Alcohol

ASAPCC Alcohol TestNASAP Alcohol TestLACC Alcohol Test
FormFox also submitted?*

YesNo
FormFox Test Code
Observed Specimen?

YesNo
Respiratory Testing*

OSHA Respirator QuestionnairePulmonary Function Test (PFT)1/2 FaceFull Face
Full Face Mask:*
1/2 Face Mask:*
Audio Testing*

BaselineComparisonRe-test
Vision Testing*

IshiharaJaegarTitmus
Lab Test

CMP/CBC/LiverCBCUrinalysisBlood Lead / ZPPUrine PhenolBlood BenzeneHemoccultHIVRPR/VDRLTB SkinTB Gold - bloodworkOther
X-Rays

Chest X-RayLumbar X-Ray
Chest X-Ray Views*

121 view b-reader
Lumbar X-Ray Views*

235
Other Medical Services

EKGOther
Immunization
Additional Information for Clinic:
Should be Empty:

Authorization for Testing

Company Information

Testing Information

Requested Testing