Medi Center Hours

M–F  7am - 6pm
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Medi Center Services

Authorization to Treat
Items followed by (*) are required fields.
Company Name (*)
(REQUIRED) Please type your company name.
Staffing Agency
Name of person authorizing treatment.
Patient Name (*)
(REQUIRED) Please enter Patient Name
Last 4 digits of Social Security number. (*)
(REQUIRED) Please type the last four digits of your social security number.
Date
MM/DD/YYYY
Authorized By (*)
(REQUIRED) Please include Authorized By
Person authorizing email address (*)
(REQUIRED) Please supply a valid Email Address
Employer Phone (*)
(REQUIRED) Please supply the Employer Phone Number.

INJURY
Treatment/Evaluation



NON-DOT PROCEDURES
Physical Examination







DRUG TEST
Drug Test Type

Test @ HMC-rapid screen
Invalid Input
Reason for Drug Test






Invalid Input

ALCOHOL TEST
Breath Alcohol Test Type
Reason for Alcohol Test






Invalid Input

DOT PROCEDURES
Physical Examination



DRUG TEST
Drug Test Federally Mandated
Reason for Drug Test






Invalid Input
Specify DOT Agency





Invalid Input

ALCOHOL TEST
Breath Alcohol Test Type
Reason for Alcohol Test






Invalid Input
Other














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Other Notes: Hepatitis Vaccine #, Labs, TB single or 2 step, Lift test weight, Titer type.
Hepatitis Vaccine #, Labs, TB single or 2 step, Lift test weight, Titer type.
Company Instructions: other testing and/or company specific instructions.
Other testing and/or company specific instructions.
  

335 N. 120th Avenue  •  Holland, MI 49424  •  Phone: 616.392.5222  •  Fax: 616.392.3653
Copyright © 2005-2008. Holland Medi Center