Download Authorization to Treat Employee

Precision Medical and Occupational Health
When going to ER, please have someone escort you to
the lab for your post accident drug screen, if applicable.
3837 W US 10, Ludington, MI 49431 (231) 843-6200
www.precisionmedicalocchealth.net
Rodney L. Kilpatrick, D.O., Medical Director
Authorization to Treat Employee
Please Call to Schedule Services
Exam Is Scheduled For:
Monday through Thursday / 8a – 5p
Friday / 8am – Noon
CLOSED DAILY Noon – 1pm
Date:
PH: (231) 843-6200 FAX: (231) 843-3388
PMOH is located near the SE corner of US 31
and US 10, 300 yards East of Home Depot,
directly behind Staples
Time:
Employee Instructions:
Bring Photo ID
If Applicable - Bring Copy of
Initial Injury Report
Employee:
DOB:
 Employer  Work Comp
Bill To:
Billing Address/
City:
St/Zip:
Contact Name:
Phone:
Fax:
Health Care Services Requested
Treatment
Authorization:
Designated Employer Representative (DER) signature
Title
If Injury/Problem
Onset Date:
Nature of Visit:
 Tier 1 – Pre-Placement (cursory Physical Exam only)
Back Stability Exam
 Tier 4 – Pre-Placement (Tier 3 plus review of 3 or more ancillaries)







 D.O.T Physical

Immunization: _______
 Other _________________________________________________
 X-Rays: ________________
Employee Injury:  Initial Visit  Follow-Up  Re-Open Case
 Labs: __________________
 Tier 2 – Pre-Placement (Physical Exam w/ Functional Assessment)
 Tier 3 – Pre-Placement (Tier 2 plus review of 1 or 2 ancillary labs/x-rays. etc.)
Saliva Alcohol Screen
Breath Alcohol – At Hospital
Urine Drug Screen
Instant Drug Screen
Saliva Drug Screen
TB Test
Employee Authorization to Release Information
I,
Patient Name
Date of Birth
Hereby authorize Precision Medical and Occupational Health to release medical record information to my above identified
employer, including alcohol and drug abuse records protected under the regulations in the 42 Code of the Federal
Regulations, Part 2, or any information which may pertain to the diagnosis, evaluation, or treatment of any mental or
emotional condition or disorder pertaining to my occupational health services.
I also authorize my ER records to be sent to PMOH by fax for follow-up care. The fax number is (231) 843-3388.
Updated 1/15
Signature of Patient
Date
Witness
Date
Precision Medical and Occupational Health
3837 W US 10, Ludington, MI 49431 (231) 843-6200
www.precisionmedicalocchealth.net
Rodney L. Kilpatrick, D.O., Medical Director
Updated 1/15
When going to ER, please have someone escort you to
the lab for your post accident drug screen, if applicable.