MED-1 AUTHORIZATION FORM

PHOTO ID REQUIRED

* Required Fields
Company Name*: Staffing Agency:
Patient Name*: Date: valid for 48 hours
Authorized By*: Employer Telephone #*:
  INJURY
INJURY
Treatment/Evaluation
Treatment of alleged work-related injury or illness
Drug Screen with initial visit
Breath Alcohol Test with initial visit

What is the type of injury or illness:
  NON - DOT PROCEDURES DOT PROCEDURES
PHYSICAL
EXAMS
Physical Examination
Physical Examination
DRUG TESTS
Drug Test - Type (Check all that apply)
Urine Rapid Collection Only Hair Saliva Observed
Urine Panel Type: Rapid Panel Type:

Saliva Panel Type:
Reason for Drug Test

Drug Test - Federally Mandated
Urine Collection Only
Reason for Drug Test
ALCOHOL
TESTS
Breath Alcohol Test - Type
Breath Alcohol Test
Reason for Alcohol Test
Alcohol Test - Federally Mandated
Breath Alcohol Test
Reason for Alcohol Test
OTHER
Hepatitis B Vaccine # Chest X-Ray Pulmonary Function Test Labs TB Skin Test Single 2 Step TB Blood Test Audio Test Vision Test Lift Test #
COMPANY INSTRUCTIONS
Other testing and/or company specific instructions: 250
MED-1 INSTRUCTIONS
  • Please arrive 30 minutes prior to close
  • Physical Exam: Please bring glasses or contacts
  • Drug Screening: Do not urinate prior to arrival
  • Pulmonary Function Test: Do not eat, use an
    inhaler, or smoke one hour prior to arrival

Click the corresponding 'Submit' button for the MED-1 location destination for this authorization.


MED-1 Leonard
1140 Monroe Ave, Ste. 150
Grand Rapids, MI 49503
Phone: (616) 459-6331

MED-1 Breton
4433 Breton Ave SE
Kentwood, MI 49508
Phone: (616) 281-6000

MED-1 Holland
383 Garden Ave
Holland, MI 49424
Phone: (616) 494-8271
Submitting