Transcription of Occupational Medicine Authorization Form (for Employer)
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Occupational Medicine Authorization Form (for Employer)
Rev. 09/02/22 [OCC-F001-(09-22)] 2022 Doctors Care is a registered trademark of UCI Medical Affiliates, Medicine /WKC Authorization Form (for Employer) Complete this form (all fields) and present at time of serviceOcc Med Billing Hotline - Call Extension 5007703 or 803-724-5860 Occ Med Service Support - Call 888-845-6887 Visit for the most current : Patient Name: Employer: Phone: Fax: Employer Address: Primary Contact: Email: Hair 5 Panel Drug Screen, non-DOT ( )Hair Collection Only ( )5 Panel In-house Drug Screen non-DOT ( )10 Panel In-house Drug Screen non-DOT ( )5 Panel External Lab DOT Drug Screen ( )5 Panel External Lab Drug Screen, non-DOT ( )10 Panel External Lab Drug Screen, non-DOT ( )Urine Collection Only, DOT ( )Urine Collection Only, non-DOT ( )Breath Alcohol Test DOT ( )Breath Alcohol Test non-DOT ( )DOT P
Occupational Medicine Authorization Form (for Employer) Complete this form (all fields) and present at time of service Occ Med Billing Hotline - Call Extension 5007703 or 803-724-5860 • Occ Med Service Support - Call 888-845-6887 Visit https://employers.doctorscare.com for the most current forms. Date: Patient Name: Employer: Phone: Fax:
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