Authorization for Testing
Company Information
Company Name
*
Authorized By
*
First Name
Last Name
Phone Number
E-mail
*
Employee Information
Employee Name
*
First Name
Last Name
Employee Social Security Number
Please Use Dashes
Employee Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Job Name
If Applicable
PO Number
*
Business Line
*
Turnaround
Maintenance
Construction
Specialty Services
Reason For Visit
*
Pre-Employment
Random
Annual
Post Incident
Reasonable Suspicion
Other
Date of Testing
*
-
Month
-
Day
Year
Date Picker Icon
Testing Facility
*
IN HOUSE HIRING CENTER
Main Clinic - 15389 Airline Hwy, Baton Rouge
Gonzales Safety Council - 1205 W. Edenborne Pkwy, Gonzales
Baton Rouge Safety Council - 10099 N. Reiger Rd, Baton Rouge
Addis Safety Council - 7640 Highway 1, Addis
Reserve Clinic - 3919 W. Airline Hwy, Reserve
Walker Safety Council - 29756 Walker South Rd, Walker
Any Lab Test Now- Baytown, Tx.
Business Health Partners- 3649 S. Beglis Parkway, Sulphur, La.
JOB SITE SPECIFIC ORDERS
BASF
SENECA SOUTH CAROLINA
BASF SENECA
non-DOT physical
Drug Screen #2683
Baseline Audio
PFT
Urine Dip (In House)
3m 6000 1/2
Scott AV2000 FF
WR GRACE
Baton Rouge
Lake Charles
Norco
job# 1000278
PO# 420033857
Facility# 471059
Pit Assessment
PFT
MSA ULTRAVIEW FF
Saliva Alcohol
12 panel instant check
Non-DOT drug screen panel 2683
job# 1000495
Facility# 471059
Brown and Root Assessment
12 panel instant check
Non-DOT drug screen panel 2683
job# 1000496
Facility# 471059
Brown and Root Assessment
12 panel instant check
Non-DOT drug screen panel 2683
Job #1000193 - Lion Elastomers (PO# 5348) -12 Panel Instacheck -Respiratory Clearance -Fit Test - MSA Ultraview FF -Brown and Root Assessment
Job #1000192 - Lion Elastomers (PO# 5184) -12 Panel Instacheck -Respiratory Clearance -Fit Test (x3) - MSA Ultraview FF, Scott AV2000 FF, North 7700 1/2F -Brown and Root Assessment
Job #J131 (PO# 4200005458) -12 Panel Instacheck -Respiratory Clearance -Fit Test - Scott AV2000 FF -Brown and Root Assessment
Annual Fit Test Job #J131 (PO# 4200005458) -Respiratory Clearance -Fit Test - Scott AV2000 FF
Job# J137 -Celenese (Wilmington, NC) -12 Panel Instacheck -Brown and Root Assessment
Job# 1000273- Clarksville, TN -Alere Drug Screen Facility # 431840 panel # 2683 -12 panel Instacheck
Job #1000285 -12 Panel Instacheck -Non DOT Breath Alcohol -Respiratory Clearance -Fit Test - MSA Ultraelite FF -PIT Assessment
PHYSICAL EXAMINATIONS
Physical Examination
Brown and Root Assessment
DOT Physical
Return to Work Physical
Fit for Duty Physical
Operators Physical
Hazwoper Physical
CCO Physical
Diamine Physical (includes clearance)
ASAP TESTING
ASAP DRUG SCREEN
ASAP NASAP
ASAP LACC
ASAP BREATH ALCOHOL
Non-DOT breath alcohol
DISA TESTING
DISA Alcohol
Non-DOT Breath Alcohol Test
DOT Breath Alcohol Test
DISA Drug Screen
DOT Drug Screen Collection
DCCHA Urine Drug Screen
DCCEO Urine Drug Screen
DCCOF Oral Fluid Drug Screen
DCCHT Hair Test WITHOUT Randoms
DCCHT Hair Test WITH Randoms
Other
DRUG SCREENS (NON-DISA)
Non-DOT Collection with Results
Non-DOT Drug Screen with Results (Enter Panel Number Below)
Drug Screen Panel
Enter Panel Number
Non-DOT Collection Only
Non-DOT Drug Screen (Enter Requested TPA Below)
TPA
Enter Requested TPA
DOT Drug Screen (Receiving Results from Gulf Coast)
DOT - FMCSA
DOT - PHMSA
Other
DOT Collection without Testing (Chain of Custody Provided)
DOT - FMCSA
DOT - PHMSA
Other
Instacheck
5 Panel
10 Panel
12 Panel
Hair Testing
5 Panel Hair
9 Panel Hair
Other
Observed Specimen? (Charges May Apply)
Yes
No
ALCOHOL (NON-DISA)
Alcohol Testing Type
Non-DOT
DOT
Breath
Saliva
TPA
ASAP
Forward Edge
Other
AUDIO TESTING
Audio Testing
Baseline Audiogram
Annual Audiogram
Threshold Shift Comparison (Additional Charge)
RESPIRATORY TESTING
Respiratory Testing
Fit Test (Select Mask Below)
Respiratory Clearance
PFT
Fit Test Masks
North 7660 Full Face
North 7700 1/2 Face
3M 6000 1/2 Face Series
3M 6800 Full Face Series
3M 7800 Full Face Series
MSA Comfo Classic 1/2 Face
MSA Ultraview Full Face
Scott 66 1/2 Face
Scott Oramic Full Face
Scott AV 2000 Full Face
Other
LAB BLOOD WORK
Labs
CMC
CMP
Benzene
Lead/ZZP
Executive Profile (CBC, CMP, Lipids)
Other
X-RAYS
X-Rays
Chest 1 View
Chest 2 View
Lumbar 3 View
Lumbar 5 View
Other
INJURIES OR OTHER NEEDS
Please Specify
Please send all results to
*
network@gulfcoastoccmed.com
Back
Next
Submit
Should be Empty: