Occupational Health Authorization for Work Related Injury Care

Occupational Health Services

AUTHORIZATION FOR WORK RELATED INJURY CARE
Injury Care Locations and Service Hours
Location:

Occupational Health ServicesUrgent CareEmergency Center - Okemos
Sparrow Occupational Health Services
Injury Care Hours: Monday-Friday from 7 a.m. to 4:30 p.m.
Sparrow Medical Arts Building | 1322 E. Michigan Avenue, Suite 101, Lansing, MI 48912
Phone: 517.364.3900, Option 1 | Fax: 517.364.3914 | Email: SparrowOHS@sparrow.org

* Please schedule an appointment if the injury occured over 24 hours ago

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

Sparrow Urgent Care (after-hours injury care)
Injury Care Hours: Monday-Friday from 4:30 p.m. to 8 p.m./Weekends & Holidays: 8 a.m. to 8 p.m.

Michigan Avenue 1120 E. Michigan Avenue Lansing, MI 48912	Grand Ledge 1015 Charlevoix Drive Grand Ledge, MI 48837
East Lansing 2682 E. Grand River Avenue East Lansing, MI 48823	Mason 800 E. Columbia Street Mason, MI 48854

Sparrow Emergency Center - Okemos
Injury Care Hours: Non-Emergent Injuries 8 p.m. to 8 a.m. / Emergent Injuries 24/7
2446 Jolly Road Suite A, Okemos, MI 48864

* Breath Alcohol Testing & Drug Tests are NOT available at Urgent Care or Emergency Center
Employee Information:
Patient's Name*
Date of Birth*

MonthDayYear
Authorizing Company*
Employee Email
Injury Information:
Date of Injury*

MonthDayYear
Description of Injury
Workers' Compensation Carrier*
Workers' Compensation Claim Number
Workers' Compensation Address
Post-Accident Drug and Alcohol Testing

(Photo Identifaction Required)
* Breath Alcohol Testing & Drug Tests are NOT available at Urgent Care or Emergency Center
Breath Alcohol Testing & Drug Test:

Non-DOT Breath Alcohol TestDOT Breath Alcohol Test
Lab Based Urine Drug Test:

DOT Urine Drug ScreenUrine Drug Screen (Non-DOT)Urine Drug Screen Collection OnlyOther/Special Instructions
RAPID Urine Drug Tests:

4 Panel Rapid (No THC)5 Panel Rapid9 Panel Rapid (No THC)10 Panel Rapid11 Panel Rapid
I request and authorize the above-named employee to receive injury care from Sparrow Health Services.

I further understand that my company will be financially responsible for any and all authorized services in the event my workers compensation insurance carrier denies the charges for any reason.
Supervisor's Signature*

Clear
Printed Name*
Date*

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

Occupational Health Services

Injury Care Locations and Service Hours

Employee Information:

Injury Information:

Post-Accident Drug and Alcohol Testing