Gulf Coast Authorization

Authorization for Testing
Company Name
Company Name
Authorized By:
Phone Number
Format: (000) 000-0000.
E-mail
Employee Information
Employee Name
Employee Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Job Number / PO Number
If Not Applicable, Type N/A
Date of Testing

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Visit
Testing Facility
Billing
Please Send All Results to
Network Testing
Zip Code for Testing
Patient's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Email Address
example@example.com
Network Requested Testing
Network Testing - Click All That Apply
Network Physical Exams
Network Physical Exams
Network Drug Screening
Network Drug Screens (Non-DISA)
Network Instacheck
Network Drug Screen Panel
Network DOT Drug Screen (Results to Gulf Coast) Agency
Network Hair Testing (Results to Gulf Coast)
Network Observed Specimen? (Charges May Apply)
Network Alcohol Testing
Network Alcohol Testing Type
Network Audio & Vision Testing
Network Audio Testing
Network Vision Testing
Network Respiratory & Fit Testing
Network Respiratory Testing
Network Fit Test Masks

Other
Please provide your employee with any dust mask/N95 for fit testing
Network Blood Laboratory Testing, Vaccines, and X-Rays
Labs
Vaccines
X-Rays
Local Testing
Check All That Apply.
Physical Examinations
Special Work-Ups
Physical Examinations
DISA/ASAP Testing
DISA Drug Screens

Other
ASAP Testing
DISA Alcohol
FormFox also submitted?
FormFox Authorization Code (If Available)
Observed specimen? (Charges may apply)
Drug Screening
Drug Screens
Instacheck

Other
Non-DOT Drug Screen Panel
Non-DOT Collection
DOT Drug Screen (Results to Gulf Coast) Agency

Other
DOT Collection (Chain of Custody Provided) Agency

Other
Oral Fluid
Hair Testing
Observed Specimen? (Charges May Apply)
Alcohol Testing
Alcohol Testing Type
Audio & Vision Testing
Audio Testing
Vision Testing
Respiratory & Fit Testing
Respiratory Testing
Fit Test Masks

Other
Please provide your employee with any dust mask/N95 for fit testing
Blood Laboratory Testing, Vaccines, and X-Rays
Labs

Other
Vaccines
X-Rays

Other
Injuries
Name of Escort (If Not Authorizing Individual)
First & Last Name
Phone Number of Escort
Please enter a valid phone number.Format: (000) 000-0000.
Information About the Injury
Virtual Visits
Virtual Visit / Telehealth
Date of Injury/Incident

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Personal or Work-Related?
Mechanism of Injury
Treatment Details
Does the patient have a release from their doctor?
Please Upload the Release

Cancelof
Contact Number for Virtual Visit (Must Be Smart Device with Camera Access)
Format: (000) 000-0000.
State the Patient is Located
Time Frame Which Patient Can Be Contacted
Company Representative (If Present)

First NameLast Name
Special Notes
Should be Empty:

Authorization for Testing

Company Name

Employee Information

Network Testing

Network Requested Testing

Network Physical Exams

Network Drug Screening

Network Alcohol Testing

Network Audio & Vision Testing

Network Respiratory & Fit Testing

Please provide your employee with any dust mask/N95 for fit testing

Network Blood Laboratory Testing, Vaccines, and X-Rays

Local Testing

Physical Examinations

DISA/ASAP Testing

Drug Screening

Alcohol Testing

Audio & Vision Testing

Respiratory & Fit Testing

Please provide your employee with any dust mask/N95 for fit testing

Blood Laboratory Testing, Vaccines, and X-Rays

Injuries

Virtual Visits