Print Form
DOT Physical Authorization Form
** All services require photo
identification to be provided
DIRECTIONS:
by employee at time of service.
Complete all Sections A - D entirely
( Only services marked on this form will be completed )
This is authorization to provide medical services to:______________________________________________ DOB________________
SS# ______________________
( Print Patient Name Above)
Section A: Employer Information
Section B:
Physical Examination
Section C: Urine Drug/Alcohol Tests
Urine Drug Screens
Donor will bring Physical Exam Form
O Yes
O No
Employer Name:
O
Collection Only / Donor will bring COC
O DOT Physical Exam
Florida Drug Free Workplace
Address:
O
5 Panel HRS
O
8 Panel HRS
These Additional Services MA
Y BE Required
O 10 Panel HRS
DOT
Phone #
Will Employer pay for the additio
n
al Services ?
O
DOT / NIDA
Alcohol Testing
O Yes
O Yes
O No
O No
Fax #
#
Lake
Lake Ella, Appleyard,
Ella, Appleyard,
North & Mahan Locations Only
O Spirometry – Pulmonary Function
Third Party Administrator
O DOT Breath Alcohol Test
O Audiometry
Name:
O Non – DOT Breath Alcohol Test
O Vision Test - Keystone
Additional Comments/ Notes:
O Glucose Finger Stick
O Electrocardiogram (EKG)
Address:
Phone #
Fax #
Section D: Authorization Information
Print Name of Authorizer:
Authorizer Signature:
Phone #
Title:
Date:
Fax or Mail results to:
For Patients First Use Only: Phone Auth received by:
Billing: Please mark responsible billing party
O Bill Employer
Date & Time
O Bill Thi d
O Bill Third Party Administrator
r Party
Ad
minist tor
ra