Gulf Coast Authorization

Authorization for Testing
Company Information
Company Name*
Authorized By:*
Phone Number*
E-mail
Employee Information
Employee Name*
Employee Date of Birth

MonthDayYear
Date
Job Number / PO Number*
If Not Applicable, Type N/A
Date of Testing*

MonthDayYear
Date
Reason for Visit*
Testing Facility*
Testing Facility*

Virtual Visit / TelehealthGCOM Main Clinic - 15389 Airline Hwy, Baton RougeGCOM Gonzales Safety Council - 1205 W. Edenborne Pkwy, GonzalesGCOM Baton Rouge Safety Council - 10099 N. Reiger Rd, Baton RougeGCOM Addis Safety Council - 7640 Highway 1, AddisGCOM Reserve Clinic - 3919 W. Airline Hwy, ReserveGCOM Walker Safety Council - 29756 Walker South Rd, WalkerGCOM Geismar Clinic- 6105 Highway 73, GeismarBHP Sulphur Clinic - 3649 S. Beglis Pkwy, SulphurBHP Nederland Clinic - 1005 Nederland Ave, Nederland, TXBHP Deer Park Clinic - 1806 Center Street, Deer Park, TXBHP Corpus Christi Clinic - 7406 Up River Rd, Corpus Christi, TXBHP McAllen Clinic - 422 E. Dove Ave, McAllen, TX
Billing*

Bill my existing Business Health Partners accountSend results and billing to Gulf Coast for Medical Management
Please Send All Results to
Network Testing
Zip Code for Testing
Patient's Phone Number
Please enter a valid phone number.
Patient's Email Address
example@example.com
Network Requested Testing
Click All That Apply

Physical ExamDrug Screening (Non-DISA)Alcohol Testing (Non-DISA)Respiratory and Fit TestingAudio and Vision TestingLab Blood Work, Vaccines, and X-Rays
Network Physical Exams
Network Physical Exams

Non-DOT PhysicalDOT PhysicalReturn to Duty Physical
Network Drug Screening
Drug Screens (Non-DISA)

InstacheckDrug Screen (Results to Gulf Coast)DOT Drug Screen (Results to Gulf Coast)Hair Drug Screen Collection
Instacheck

5 Panel10 Panel
Drug Screen Panel

DOT Panel#1200 - 5 Panel#958 - 10 Panel#859 Extended Synthetic THC
DOT Drug Screen (Results to Gulf Coast) Agency

FMCSAPHMSAUSCG
Hair Testing (Results to Gulf Coast

5-Panel Hair Test
Observed Specimen? (Charges May Apply)

YesNo
Network Alcohol Testing
Alcohol Testing Type

Non-DOT BreathDOT Breath
Network Audio & Vision Testing
Audio Testing

AudiogramThreshold Shift Comparison (Additional Charge)
Vision Testing

Visual Acuity (Near, Far, Color, Depth)
Network Respiratory & Fit Testing
Respiratory Testing

Respiratory ClearancePFT (Pulmonary Function Test)Fit Test
Fit Test Masks

North 7660 Full FaceNorth 7700 1/2 Face3M 6000 1/2 Face Series3M 6000 Full Face Series3M 7800 Full Face SeriesMSA Advantage 200 Half FaceMSA Comfo Classic 1/2 FaceMSA Ultraview Full FaceScott 66 1/2 FaceScott Oramic Full FaceScott AV 2000 Full FaceScott AV 3000 Full FaceOther
Please provide your employee with any dust mask/N95 for fit testing
Network Blood Laboratory Testing, Vaccines, and X-Rays
Labs

Hemoglobin A1CHepatitis B TiterHepatitis C TiterLipid PanelMMR TiterVaricella TiterTB Skin Test
Vaccines

Hepatitis AHepatitis BMMRVaricella
X-Rays

Chest 1 ViewLumbar 3 View
Requested Testing
Check All That Apply.*

Physical ExamDISA/ASAP TestingDrug Screening (Non-DISA)Alcohol Testing (Non-DISA)Respiratory and Fit TestingAudio and Vision TestingLab Blood Work, Vaccines, and X-RaysInjuries
Physical Examinations
Special Work-Ups

HAZMAT - Physical, PFT, Chest X-ray, CBC/CMPCrystalline Silica - Physical, PFT, B-Reader Chest X-Ray, TB SkinDiamine - Physical, Urinalysis, Urine Cytology, CMP/CBC/LipidAsbestos - Physical, Clearance, PFT, Chest X-RayMarathon - Physical, Marathon Questionnaire
Physical Examinations

DOT PhysicalNon-DOT PhysicalQuantitative PhysicalReturn to Work PhysicalFit For Duty PhysicalCoast Guard PhysicalOperator PhysicalSafety Senstive PhysicalRange Of Motion PhysicalPhysical Abilities ExamHuman Performance Evaluation (HPE)
DISA/ASAP Testing
DISA Drug Screens

DOT Urine Drug ScreenDCCHA Urine Drug ScreenDCCEO Urine Drug ScreenDCCOF Oral Fluid Drug ScreenDCCHT Hair Test WITH RandomsDCCHT Hair Test WITHOUT RandomsNASAP Urine Drug ScreenOther
ASAP Testing

LACC Drug ScreenLACC Alcohol TestASAPCC Drug ScreenASAPCC Alcohol TestNASAP Drug ScreenNASAP Alcohol Test
DISA Alcohol

Non-DOT Breath Alcohol TestDOT Breath Alcohol TestNon-DOT Saliva Alcohol Test
FormFox also submitted?

YesNo
FormFox Authorization Code (If Available)
Observed specimen? (Charges may apply)

YesNo
Drug Screening
Drug Screens (Non-DISA)

InstacheckNon-DOT Drug Screen (Results to Gulf Coast)Non-DOT Collection (Chain of Custody Provided)DOT Drug Screen (Results to Gulf Coast)DOT Collection (Chain of Custody Provided)Oral Fluid Drug Screen CollectionHair Drug Screen Collection
Instacheck

5 Panel10 Panel12 Panel
Non-DOT Drug Screen Panel
Non-DOT Collection

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

FMCSAPHMSAUSCGOther
DOT Collection (Chain of Custody Provided) Agency

FMCSAPHMSAUSCGOther
Oral Fluid

Oral Fluid
Hair Testing

5-Panel Hair Test10-Panel Hair Test
Observed Specimen? (Charges May Apply)

YesNo
Alcohol Testing
Alcohol Testing Type

Non-DOT BreathDOT BreathNon-DOT Saliva
Audio & Vision Testing
Audio Testing

AudiogramThreshold Shift Comparison (Additional Charge)
Vision Testing

Visual Acuity (Near, Far, Color, Depth)
Respiratory & Fit Testing
Respiratory Testing

Respiratory ClearancePFT (Pulmonary Function Test)Fit Test
Fit Test Masks

North 7660 Full FaceNorth 7700 1/2 Face3M 6000 1/2 Face Series3M 6000 Full Face Series3M 7800 Full Face SeriesMSA Advantage 200 Half FaceMSA Comfo Classic 1/2 FaceMSA Ultraview Full FaceScott 66 1/2 FaceScott Oramic Full FaceScott AV 2000 Full FaceScott AV 3000 Full FaceOther
Please provide your employee with any dust mask/N95 for fit testing
Blood Laboratory Testing, Vaccines, and X-Rays
Labs

CBCCMPBenzeneLead/ZZPExecutive Profile (CBC, CMP, Lipids)TB Skin testTB T-Spot Blood TestOther
Vaccines

TetanusHepatitis AHepatitis BFlu
X-Rays

Chest 1 ViewChest 2 ViewLumbar 3 ViewLumbar 5 ViewOther
Injuries
Name of Escort (If Not Authorizing Individual)
First & Last Name
Phone Number of Escort
Please enter a valid phone number.
Information About the Injury
Virtual Visits
Virtual Visit / Telehealth*

Fit For Duty / Return to Duty AssessmentNurse Triage for Injury/Illness
Description of Incident
Contact Number for Virtual Visit
State the Patient is Located
Time Frame Which Patient Can Be Contacted
Special Notes
Company Representative (If Present)

First NameLast Name

Authorization for Testing

Company Information

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

Requested 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

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