Authorization For Examination Or Treatment Chart

Download a blank fillable Authorization For Examination Or Treatment Chart in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Authorization For Examination Or Treatment Chart with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Highlighted fields are required
Authorization for Examination or Treatment
Occupational Medicine
3838 12th Ave. N.
Fargo, ND 58102
(P) (701) 234-4700
EMPLOYER is to mark all services required.
(F) (701) 234-4757
Name:
_________________________
_______________________
______
Patient
LAST
FIRST
MI
DOB: _______ / _______ / _______
Date of Injury: ______ / ______ / ______
Company
Work Related
North Dakota State University
Dept #
___________________________________________
_____ Injury
_____ Illness
Name:
PO Box 6050
_______________________________________________
Address:
*Please indicate in Substance Abuse Testing section if
drug AND/OR alcohol screen is required post accident.
Fargo
ND
58108
_______________________
________
__________
City
State
Zip
INJURY/SCREENING INFORMATION
Substance Abuse Testing (Drug test)
Physical Examination:
*(Photo ID Required)
Select One:
Select One:
DOT Medical Card Exam
Reason for Screen:
________
Preplacement Physical*
________
Annual
________
Recertification Physical
________
Follow-up (Non-Regulated)
* If Drug Screen is also required please mark right side
________
Follow-up - DOT (Observation required)
Exam
________
Insurance
________
Preplacement Job Title_______________
________
Post accident/injury
________
Annual / Periodic
________
Pre-employment
________
Other:___________________________
________
Random
________
Reasonable suspicion
Special Exam
________
Return to Duty (Non-Regulated)
________
Asbestos
________
Return to Duty - DOT (Observation required)
________
Respirator
Select One:
________
Medical Surveillance
Drug Screen Type:
________
DOT Urine Drug Screen (Regulated)
Additional Testing
FMCSA
FAA
FRA
FTA
PHMSA
USCG
________
Audiogram
________
Non-Regulated Urine Drug Screen
________
HPE
________
Non-Regulated Urine Rapid Screen
________
Pulmonary Function Test
________
Hair Collection
________
Respirator Fit Test
Alcohol Screen Type:
________
SFT
________
DOT Breath (Regulated)
________
TB / Mantoux Test / PPD
________
Non-Regulated Breath
________
Other:____________________________
________
Non-Regulated Blood
Billing Information (select one):
X
_____ Bill Company
_____ Third Party Administrator _________________________
_____ Employee to pay charges
_____ Worker’s Comp __________________________________
Evaluation of the NDSU Employee Respirator Medical Questionnaire
Special Instructions: _____________________________________________________________
Authorized by: ___________________________
Phone:__________________ Date:____________ Time:___________
(MUST BE SIGNED)
Authorization for Examination
Sanford Health
MR 40390 p. 1 of 2 Rev. 2/11
or Treatment
PERMANENT CHART COPY

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Authorizations For Use Or Disclosure Of Medical Record Information Authorizations For Use Or Disclosure Of Medical Record Information Legal
Authorization For Use Or Disclosure Of Protected Health Information Authorization For Use Or Disclosure Of Protected Health Information Legal
Authorization For Use Or Disclosure Of Health Information Authorization For Use Or Disclosure Of Health Information Business
Authorization For Use Or Disclosure Of Health Information Form Authorization For Use Or Disclosure Of Health Information Form Business
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Authorization For Use Or Disclosure Of Protected Health Information Authorization For Use Or Disclosure Of Protected Health Information Business
Authorization For Use Or Disclosure Of Patient Health Information Form Authorization For Use Or Disclosure Of Patient Health Information Form Business
Authorization For Use Or Disclosure Of Health Information Authorization For Use Or Disclosure Of Health Information Medical
Form Ca-16 - Authorization For Examination And/or Treatment - U.s. Department Of Labor Form Ca-16 - Authorization For Examination And/or Treatment - U.s. Department Of Labor Legal

Related Categories

Parent category: Medical
Download
Go