Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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.