Occupational Health Employer Authorization For Treatment / Billing

Occupational Health Services

Employer Authorization for Treatment/Billing
Sparrow Medical Arts Building | 1322 E. Michigan Avenue, Suite 101, Lansing, MI 48912

Phone: 517.364.3900, Option 1 | Fax: 517.364.3914 | sparrowohs@sparrow.org

Business Hours: Monday – Friday, 7:00am to 4:30pm

* Please inform employee that No Children are permitted in the clinic.

* Employees must have a scheduled appointment for physicals, pulmonary function tests, audiograms, and respirator fit testing.

* Drug & alcohol testing is provided on a walk-in basis.
Has the company set up an account with UofM Sparrow Occupational Health?*

YesNo
IMPORTANT: If the company has not yet created an account with Occupational Health you must contact UofM Sparrow Occupational Health first to do so prior to submitting this form. They can be reached at the contact info above.
Employee Name*
DOB*

MonthDayYear
Employer*
Employer Phone
Employee Department (if applicable)
Physical Exam

(bring eyeglasses and/or contact lenses and case)
Job Title/Duties
Post-offer/Pre-hireDOT—new hireMCOLESDOT—recertFitness for DutyRespirator ClearanceHazmatReturn to WorkAnnualOther/Special Instructions
Drug and Alcohol Testing

(photo identification required)
Reason for Test:

Pre-hireRandomPost accidentReasonable SuspicionReturn to dutyFollow UpOther
Type of Test:

DOT Urine Drug ScreenUrine Drug ScreenRapid Drug Test Panel:DOT Collection OnlyHair TestingOral Fluid TestDOT Breath AlcoholBreath AlcoholCollection Only
Select the Rapid Panel Needed (if applicable)

4 (No THC)59 (No THC)1011
Screening / Immunization
Services Requested:

Audiogram (No Analysis)Audiogram w/Analysis (OSHA)EKGVision ScreenTB Test (PPD)Vaccination (enter below if applicable)Titer(s) (enter below if applicable)Quantiferon TB TestRespirator QuestionnaireRespirator Fit Test (No Beards)Pulmonary Function Test (PFT)Chest X-rayOther
Vaccinations or Titers if applicable:
Special Instructions
I request and authorize the above-named employee to receive the service from Sparrow Health System and I further understand that my company will be financially responsible for any and all authorized services.
Supervisor Signature*

Clear
Printed Name*
Date*

MonthDayYear
Contact Phone Number*
Contact Email*
example@example.com
Please verify that you are human*
Should be Empty:

Occupational Health Services

Physical Exam

Drug and Alcohol Testing

Screening / Immunization