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EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENT EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENT DISA PREFERRED COLLECTION SITE Patient Name: Company Name: Site#/Street Address: WORK-RELATED INJURY ILLNESS __ DOT Regulated __ Non-Regulated __ Rapid D/S (Instant) DOT PHYSICAL NON DOT - PHYSICAL SPECIAL PHYSICAL EXAMINATIONS Authorized By: Title: Phone: Date: BILLING __ Employee to pay charges at time of service __ Workers Compensation __ Insurance Co: __ Policy #: __ Phone #: PRE-PLACEMENT EVALUATION JOB TITLE: __ Physical Exam __ Physical Assessment __ Regulated Drug Screen __ Non-Regulated Drug Screen __ Urine Collection Only __ PFT Test __ Hair Collection __ Drug Screen __ Breath Alcohol __ Drug Screen and Breath Alcohol __ Urine Collection Only __ Regulated Drug Screen __ Urine Collection Only __ Breath Alcohol __ Pre-placement (Post-Offer) __ Recertification (Annual) __ Exit __ Audiogram __ Asbestos __ Respirator __ Regulated Drug Screen __ Hazmat __ Baseline __ Blood Work __ Hair Collection __ OGUK __ Coast Guard Physical __ Other __ Audiogram __ Fit Test __ Mask Type __ COVID-19 Nasal Swab (Lab) __ COVID-19 Blood (Lab) __ COVID-19 Rapid Test __ Vaccinations __ Periodic __ Post-accident __ Follow-up __ Pre-Placement __ Reasonable Suspicion __ Other SUBSTANCE ABUSE TESTING REASON FOR TEST __ DOT Regulated __ Non-Regulated __ Urine Collection Only __ Rapid Test __ Breath Control __ Random __ Hair Collection SSN: Date of Birth: Date of Injury: Form may be downloaded from www.wellnowhealth.net

EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR ......EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENT DISA PREFERRED COLLECTION SITE TESTING & PHYSICALS 8am-5pm (Mon-Fri) INJURY

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  • EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENTEMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENTDISA PREFERRED COLLECTION SITE

    Patient Name:Company Name:Site#/Street Address:

    WORK-RELATED INJURY ILLNESS

    __ DOT Regulated__ Non-Regulated__ Rapid D/S (Instant)

    DOT PHYSICAL NON DOT - PHYSICAL

    SPECIAL PHYSICAL EXAMINATIONS

    Authorized By: Title:

    Phone: Date:

    BILLING__ Employee to pay charges at time of service__ Workers Compensation__ Insurance Co:__ Policy #:__ Phone #:

    PRE-PLACEMENT EVALUATIONJOB TITLE:

    __ Physical Exam__ Physical Assessment__ Regulated Drug Screen__ Non-Regulated Drug Screen__ Urine Collection Only__ PFT Test__ Hair Collection

    __ Drug Screen__ Breath Alcohol __ Drug Screen and Breath Alcohol __ Urine Collection Only

    __ Regulated Drug Screen__ Urine Collection Only __ Breath Alcohol

    __ Pre-placement (Post-Offer) __ Recertification (Annual)__ Exit__ Audiogram

    __ Asbestos__ Respirator__ Regulated Drug Screen__ Hazmat__ Baseline

    __ Blood Work__ Hair Collection__ OGUK__ Coast Guard Physical__ Other

    __ Audiogram__ Fit Test__ Mask Type __ COVID-19 Nasal Swab (Lab)__ COVID-19 Blood (Lab)__ COVID-19 Rapid Test__ Vaccinations

    __ Periodic__ Post-accident__ Follow-up__ Pre-Placement__ Reasonable Suspicion__ Other

    SUBSTANCE ABUSE TESTING REASON FOR TEST__ DOT Regulated__ Non-Regulated__ Urine Collection Only__ Rapid Test__ Breath Control__ Random__ Hair Collection

    SSN:Date of Birth:Date of Injury:

    Form may be downloaded from www.wellnowhealth.net

  • Form may be downloaded from www.wellnowhealth.net

    Fax or email authorization [email protected]

    Fax or email authorization [email protected]

    EMPLOYER’S AUTHORIZATION FOR EXAMINATION OR TREATMENTDISA PREFERRED COLLECTION SITE

    TESTING & PHYSICALS8am-5pm (Mon-Fri)

    INJURY CARE8am-7pm (Mon-Fri)

    9am-2pm (Sat & Sun)

    I-45 SOUTH LOCATION676 F.M. 517 West

    Dickinson, Texas 77539Phone: 409.572.2535

    Fax: 409.572.2480

    290 LOCATION 17376 Northwest Freeway

    Houston, Texas 77040Phone: 832.919.8484

    Fax: 832.919.8446

    TESTING & PHYSICALS8am-5pm (Mon-Fri)

    INJURY CARE8am-7pm (Mon-Fri)

    9am-2pm (Sat)

    WEST RD

    JONES RD

    JERSEY VILLAGE

    SAM

    HO

    USTO

    N TO

    LLWAY


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