EmailMeForm
Employer Request & Authorization-Original
Please ensure your employee brings a valid photo ID
Choose clinic location
Please select
Brighton
Broomfield
Central Park
Federal
Fort Lupton
Lafayette
Mobile
Northglenn
Southglenn
Westminster
General Information
Employee Name
*
First
Last
Date of Birth
*
MM
/
DD
/
YYYY
Preferred Language
English
Spanish
Other
Employer/Company Name
*
Third Party Administrator Name (TPA)
Drug and Alcohol Testing
Reason for Test
Pre-Employment
Post-Accident
Reasonable Suspicion
Random
Return-to-Duty (Direct Observed)
Follow-Up (Direct Observed)
Other
Type of Drug and Alcohol Testing (select all that apply)
Urine Drug Testing
Breath Alcohol Testing
Hair Collection Testing
Type of Drug Screen
*
DOT
Non DOT
Non-DOT Options (check all that apply)
Instant
Send to Lab
Both
Type of Alcohol Testing
*
DOT
NonDOT
Covid Services
Type of Covid Testing (check all that apply)
Rapid Antigen Swab
Rapid Molecular (Abbott ID NOW) Swab
Rapid RT-PCR Swab
Online Provider COVID Visit
Vaccinations
Type of Vaccination (check all that apply)
Flu
Hep A
Hep B
Tetanus
Physical Exam
Type of Physical
Non DOT
DOT
Return to Work (Fit for Duty)
Non-DOT Physical
PreEmployment
Annual/Bi-annual
DOT Physical
New Certification
Recertification
Return to Work/For for Duty
Please Upload applicable Job Description
Workers Compensation
New Work Injury
Other Services
Please specify any other services needed
File Upload
Upload any additional Protocols or Authorization forms as needed
Billing
Direct Bill to Employer
Employee to Pay Charges
Bill to Worker's Compensation Insurance
Claim Number
Employer Name
Authorization
Designated Employer Representative (DER) Name
DER Contact Number
DER Email
DER Signature
Clear
