Authorization for Treatment and Billing

Billing address (if different than above)

Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR OT PA RI SC SD TN TX UT VA VT WA WI WV WY ZIP Code

If Billing to WC Carrier (must include information for treatment):

Insurance Carrier Name Adjuster Name Address City State AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK ON OR OT PA RI SC SD TN TX UT VA VT WA WI WV WY ZIP Code Claim # Adjuster Phone Adjuster Fax

Services Requested

For DOT, Staff needs to bring (if applicable): A1C (last 3 months), CPAP Report (6 months), Heart Condition: Echocardiogram (12 months), Stress Test (12 months)

Physical Examinations DOT Basic Physical Return to Work Fitness for Duty Respirator Physical MCOLES Physical Work Injury Specify Work Injury Other TB Testing Audiogram Vision Exam Immunization Titer Type Pulmonary Function (PFT) Respirator Questionnaire X-Ray Lift Test Other Specify Immunization Specify Titer Type Specify X-Ray Specify Other

Drug/Alcohol Testing Options (choose 1 or 2)

1. HFAH Lab (Collection, Results, MRO (if needed)) Breath Alcohol Test - DOT Breath Alcohol Test - Non-DOT DOT Urine Drug Screen (5-panel) Observed Rapid Urine Drug Screen 5 panel (non-DOT) Rapid Urine Drug Screen 4 panel (non-DOT) 4-Panel Standard Urine Drug Screen (Non-DOT) 5-Panel Standard Urine Drug Screen (Non-DOT) 6-Panel Standard Urine Drug Screen (MCOLES) 9-Panel Standard Urine Drug Screen (Non-DOT) 10-Panel Standard Urine Drug Screen (Non-DOT) Hair Drug Screen 5 panel 2. Your Company Consortium / Lab (We Collect Only – Resulted directly to you from your appointed lab) Breath Alcohol Test - DOT Breath Alcohol Test - Non-DOT Urine Drug Screen - DOT Urine Drug Screen - Non-DOT Hair Drug Screen

Consent to treat and authorization to release information

I hereby give consent to Henry Ford Jackson Occupational Health and the attending physician for examination and treatment. I also authorize release of information pertaining to this specific treatment, physical examination and testing to my employer or entity that ordered and authorized these tests. In the event that I am subject drug and alcohol testing, I hereby give my consent to Henry Ford Health System Occupational Health Services to take samples and further give consent to the same facility to forward the sample to the laboratory to perform drug testing on such samples. I further give my permission to release the result of such test(s) to Henry Ford Jackson Occupational Health Services and authorized company management.

Acknowledge Employee Name Date