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Medical Authorization Form
Masterform 97 Ver 1.3 / Baton Rouge
Company
Date of service *
Employee name *
Employee ID
Job Site Name/Job #
PO #
Scheduler name
Scheduler phone
Reason For This Visit
Pre-Employment
Pre-Placement
Annual
Random
Post-Accident
Reasonable Cause
Return to Duty
Follow-up
Repeat/Missed On-Site Services
Physical Examination
Non DOT
Hazwoper
Benzene
DOT
Silica
Vinyl Chloride
Functional Assessment
Asbestos
Other
Ancillary Test
Audiometric Test
EKG
Respirator Clearance
Pulmonary Function Test
Other
Other
Quantitative Fit Testing
3M 6000 HF
3M 8293 Dust Mask
MSA UltraElite FF
North 7700 HF
3M 6800 FF
Scott AV 3000 FF
MSA Comfo Classic HF
North 7600 FF
Scott AV 2000 FF
MSA ADV 200LS HF
MSA ADV 4000 FF
Other
Substance Abuse Testing
CORE Drug Screens
DISA/Other TPA drug screens
Breath Alcohol and Other
10 Panel Non-DOT (CORE is MRO)
DISA Non-DOT
Breath Alcohol Non-DOT
5 Panel Non-DOT (CORE is MRO)
DISA DOT
Breath Alcohol DOT
DOT (CORE is MRO)
DISA Hair
DISA BAT Non-DOT
Hair (CORE is MRO)
DISA Oral Fluid
DISA BAT DOT
Oral Fluid (CORE is MRO)
Collect Only Non-DOT
Other
10 Panel Instant
Collect Only DOT
Other
5 Panel Instant
Collect Only Hair
Other
Laboratory Test
Lead / ZPP
CBC / Industrial Chem
X-Rays
Chest 1 View
1 View w/ B Reader
2 Views
Injury Treatment
Initial Injury Visit
Follow-up injury visit
Vaccines
Flu vaccination
Tetanus/Diphtheria (Td)
TB Skin test
Hepatitis B series
Tetanus, Diphtheria, Pertussis (Tdap)
TB T-Spot Blood Draw
Comments
* Indicates a required field.
Date and time automatically recorded.
