Medexpress Employer Authorization Form PDF Details

At the core of workplace safety and compliance, the MedExpress Employer Authorization Form serves a pivotal role. This detailed form, meticulously designed, allows employers to authorize medical services for their employees, ranging from drug and alcohol testing to physical examinations and specialized services like respiratory fit tests and audiograms. The form requires basic patient information, including the patient's name, the scheduled date and time for the service, and the company's details. It also necessitates a thorough specification of the treatment authorized, encompassing a wide array of checks like DOT and non-DOT drug screenings, breath alcohol tests, and custom panel drug screens. Additionally, the form offers options for using MedExpress's lab and Medical Review Officer (MRO) or the company's own paperwork and lab services for processing. Moreover, specific to the instances necessitating these tests—such as pre-placement, post-accident, or for reasonable suspicion among others—the form ensures clarity and precision. Instructions are included for the collection of specimens, like urine or hair for drug screening, and the necessity for photo ID at the time of the test. Fees around physical examinations and other medical services like vaccinations, titers, and evaluations for return to work are also addressed, ensuring employers have a comprehensive tool for employee health and safety management. Furthermore, the form facilitates communication preferences for the delivery of results and specifies the billing address, if different from the primary address, demonstrating its all-encompassing nature in managing occupational health processes efficiently and effectively.

QuestionAnswer
Form NameMedexpress Employer Authorization Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesmed express employeer auth forms, authorization form medexpress, employer authorization med express, med express employer authorization form has no confirmation number

Form Preview Example

Employer Authorization Form

Patient Name:

 

Scheduled Date(s):

 

Time:

Company:Location:

Treatment Authorized by:

Name and Title (please print)

Signature:Phone:

Injury/Accident

Date of Injury:

 

Injured Body Part:

Please provide the above patient with the following services: (Please check all that apply)

Drug and/or Alcohol Testing (Please check type and reason below)

PLEASE SELECT EITHER OPTION 1 OR OPTION 2

OPTION 1: Using MedExpress lab and MRO

OPTION 2: Using your company paperwork, lab, and MRO

Breath Alcohol Test - Please check:

DOT or

Non-DOT

DOT Urine Drug Screen (5-panel)

 

 

Please check one:

FMCSA

FAA

FRA

 

 

FTA

PHMSA

USCG

Rapid Urine Drug Screen (Non-DOT)

 

(Please check 5-panel or 10-panel)

 

5-Panel Standard Urine Drug Screen (Non-DOT)

10-Panel Standard Urine Drug Screen (Non-DOT)

Custom Panel #:

 

 

 

 

Hair Drug Screen - Please check:

5-panel or

 

 

 

 

5-panel w/exp. opiates

Blood Alcohol Testing*

 

 

 

Oral Fluid Cotinine Test (PA ONLY)

 

 

OR

 

Collection Only

 

 

 

CCF:

Urine Drug Screen:

 

DOT

On file at center

 

Non-DOT

Donor will arrive with

Hair Drug Screen:

Hair Drug Screen

Rapid Urine Drug Screen (Non-DOT):

(Please check 5-panel or 10-panel)

Reason for Drug/Alcohol Testing:

 

Pre-Placement

Post-Accident

Reasonable Suspicion

Random

Return-to-Duty

 

Follow-Up

Observed Collection

 

PHOTO ID IS REQUIRED!

Physical Examination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Services:

 

 

 

 

 

 

Labs:

 

 

DOT - Please check

New Certification or

Re-Cert or

Follow-up

TB skin test/PPD

 

 

 

 

 

 

Lead level

 

 

Pre-Placement Basic (Non-DOT)

 

 

 

 

 

 

 

 

 

Hepatitis A vaccine

 

 

 

 

 

 

Hep B titer (HepBsAB)

 

 

Respirator Questionnaire Clearance

 

 

 

 

 

 

 

 

 

Hepatitis B vaccine

 

 

 

 

 

 

MMR titer

 

 

Return-to-Work Evaluation

 

 

 

 

 

 

 

 

 

MMR vaccine

 

 

 

 

 

 

CMP

 

 

Special company protocol/form:

 

 

 

 

 

 

 

 

 

Flu shot

 

 

 

 

 

 

CBC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EKG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional Services*:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Quantitative Resp. Fit Test

 

 

 

Qualitative Resp. Fit Test

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OSHA Pulmonary Function Test

 

 

 

Spirometry Test

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lift Testing

 

 

 

 

 

 

Audiogram OSHA Threshold

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Please call the center to verify availability of test.

 

 

DER/Company contact for results and/or physician call:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preferred communication (please check all that apply)

phone

fax (secure)

e-mail

mail

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

 

Zip Code:

 

 

 

 

E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

Ext.

 

 

 

Secure Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Billing Address (only if different than above):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

State:

 

 

 

 

 

 

Zip:

 

 

 

Phone:

 

 

 

 

 

Ext.

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If billing to carrier: Policy #

 

 

 

 

 

 

 

 

 

 

 

 

Effective Dates of Policy:

 

 

 

 

 

 

 

to

 

 

 

 

 

Company or WC Insurance Carrier:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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1. Fill out the medexpress employer authorization with a number of necessary blank fields. Collect all the required information and make sure there is nothing neglected!

Stage # 1 of completing medexpress forms for employers

2. The next stage is usually to fill in these blank fields: Panel Standard Urine Drug Screen, Panel Standard Urine Drug Screen, Custom Panel, Hair Drug Screen Please check, panel or, panel wexp opiates, Blood Alcohol Testing Oral Fluid, NonDOT, Hair Drug Screen, Hair Drug Screen, Rapid Urine Drug Screen NonDOT, Please check, panel or, panel, and Donor will arrive with.

Tips to prepare medexpress forms for employers stage 2

Those who use this PDF often make mistakes when filling in Custom Panel in this section. You should definitely revise what you type in right here.

3. The following segment is considered rather straightforward, Other, Additional Services, Quantitative Resp Fit Test, Qualitative Resp Fit Test, OSHA Pulmonary Function Test, Spirometry Test, Lift Testing, Audiogram OSHA Threshold, Please call the center to verify, DERCompany contact for results, Preferred communication please, phone, fax secure, email, and mail - all these empty fields needs to be filled out here.

The way to complete medexpress forms for employers step 3

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