Authorization for Services
Employer Name
*
Job/PO #
Job/PO #
Employee Information
*
First Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
SSN
Phone Number
-
Area Code
Phone Number
Same service for Multiple Employees?
Please Select
Yes
No
Requested Date
-
Month
-
Day
Year
Date
Appt. Time Minutes
AM
PM
AM/PM Option
Employees to be tested:
Full Name - DOB - SSN - Phone Number
Does your company have an "Employer Protocol" with our team?
Please Select
Yes
No
To have employer protocols kept on file, please contact us to get started.
Protocol Requested?
Drug & Alcohol Testing
Bridge CCFs & MRO Services
Drug & Alcohol Testing
Alcohol Testing:
BAT Non-DOT
BAT DOT
Rapid Drug Testing:
10 Panel
12 Panel
14 Panel
Observed Collection
Other
If non-negative, would you like the specimen sent to the lab for confirmatory testing?
Yes
No
Would you like to use Bridge MRO services? (Employee must provide a valid prescription)
Yes
No
For all DOT Testing, the reason for test & DOT testing authority are mandatory. Please note that options with an * are not allowable under DOT regulations.
Reason for Test:
Pre-Employment
Reasonable Suspicion
Post-Accident
Random
Follow Up
Return to Duty
Re-Test*
Pre-Access*
Return to Work*
Lab Urine Drug Screen
Please Select
Bridge Standard (14) Panel (30JK)
5 Panel (30C7)
DOT 5 Panel (W215)
Laboratory: CRL
Lab Oral Fluid
Please Select
Oral Fluid 10 Panel (PN43)
Oral Fluid 5 Panel (V371)
Laboratory: CRL
Lab Hair Follicle Drug Test
Please Select
Laboratory: Quest
Lab DOT Testing
DOT 5 Panel (W215)
DOT Breath Alcohol Test
Laboratory: CRL
DOT Testing: (Specify Agency)
FAA
FMCSA
FTA
FRA
PHMSA
USCG
TPA Drug & Alcohol Testing
(Contact our team to have your company's CCFs kept on file!)
Will you be sending a FormFox authorization?
Yes
No
Have you provided CCFs to be kept on file, or will the employee provide the CCF when they arrive for testing?
Yes
No
TPA & Other Collections
TPA
DISA
Alere
eScreen
WorkCare
ASAPCheck
TEAM
FormFox
CRL Marketplace
Other
DISA Testing: (CCF Required)
BAT
Urine Drug Screen
Hair Follicle
Oral Fluid
Consortium:
Requested Services:
Occupational Testing
Occupational Testing & Services
(If the test you are looking for is not listed, please contact our team. )
Occupational Testing:
Audiogram
Respirator Fit Test
Pulmonary Function Test
Vision Exam
Occupational Fit Testing
EKG
X-Ray & Radiology
PPD Skin Test
Lab Testing
Immunizations
Rapid Testing
Other
Audiogram:
Please Select
Baseline
Annual
Other
Respirator Mask Type:
Half Face 3M 5000/6000
Full Face SCOTT AV 3000
Half Face Comfo Classic P100
Full Face 3M 6000
Half Face GVS Elipse
Other
Respirator Testing Protocol:
Quantitative
Qualitative
Other
Occupational Fitness Testing
BOM Standard Fitness Testing
Employer-Specific Fitness Testing Protocol (If applicable)
Other
X-Ray:
Body part requiring imaging
Other Radiology Exams:
Vision Exams
Snellen
Ishihara
Jaegar
Other
Laboratory Testing
CBC
Lead + ZPP
TB Quantiferon
Heavy Metals Panel
Laboratory Testing:
Immunizations: (Please call to confirm Inventory)
TDaP
Influenza
Hepatitis B
Other
Rapid Testing:
COVID Swap
Flu Swab
Strep Swab
Other
Physical Exams
Physicals & Medical Surveillance Exams
If the exam you are looking for is not listed, please contact our team.
Exam Type:
Coast Guard (CG-719K)
DOT (CDL) Physical
Non-DOT Physical
NFPA (Firefighters)
Pre-Employment Exam
Respiratory Clearance Physical
Return to Work Exam
Fit-for-Duty
Functional Capacity Evaluation
Other
OSHA Medical Surveillance Exams:
Asbestos
Benzene
VCM
Silica
HAZWOPER
Lead
Other
FCE Request: Please list the reason for the test, who we should contact regarding your request, & any additional details.
Submission
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