Visit https://maineurgentcare.com

/ for the latest updated form

Employer Authorization Form

Date: Patient Name:

Employer: Phone: Fax:

Employer Address:

Primary Contact: Email:

WELLNESS SERVICESONSITE TRAINING SERVICES

Biometric Screening

Heart Healthy

Nutrition

Stress Relief

Diabetes

Tobacco Cessation

Weight Control

Back Care

Sleep Disorders

Men and Women’s Health

Bloodborne OSHA Training Services

Physicals - DOT/DMV

Physicals - Return to work - injury

Physicals - Return to work - sickness

Physicals - Customize based on employer

Respirator Fit Testing - half face

Respirator Fit Testing - full face

Respirator Fit Testing - N95

Pulmonary Function Test (Spirometry)

Pulmonary Function Test (Other)

Hearing Screening

Hearing Screening

Vision Screening

Vision - injury diagnosic

10 Panel Drug Test

5 Panel Drug Test

Alcohol Saliva Test (PWC)

Breath Alcohol Testing

Urine Drug Screening (regulated)

MRO Services

Immunizations - Hep A

Immunizations - Hep B

Onsite Flu vaccinations

Immunizations - MMR

Immunizations - Rabies

Immunizations - TD

Immunizations - tDAP

Flu Nasal Swab - A and B

Glucose

Hematocrit

Hemoglobin

Pregnancy Test - Urin HCG IRL

Urinalysis - dip

Urinalysis (Micro) Complete

TB Screening, Blood

TB Screening, Skin

Hepatitis A Surface Antibody

Hepatitis B Antigen

Hepatitis B Core Antibody

Hepatitis B Surface Antibody

Hepatitis C Antibody Test

Hiv 1 Test

Hiv 2 Test

Lyme Disease Serology Eval

Malaria Blood Smear Test

Measles Titer

Mercury Urine

Methemoglobin Level

Mumps Titer

Phenol, Urine

Quantiferon Test

Rabies Antibody

Rubella Titer

Rubeola Titer

Toxoplasma Igg Antibody

Toxoplasma Igm And Igg Antibody

Uds-Medpro Panel (Healthcare Workers)

Uric Acid

Varicella Titer

Urine Collection

Blood Clollection

EKG

Physical Abilities Testing (PAT) - Grip

PAT - Functional Capacity Evaluation

PAT - Lift testing

Work Rehabilitation Programs

Employee Education - health & wellness

Radiology Studies

In-house Lab (Send-outs in "ES Lab" Section)

Vaccines

Physical Therapy

Drug/Alcohol Testing

Chest X-ray (1-2 views)

X-ray of Upper Extremities (3-5 views)

X-ray of Lower Extremities (3-5 views)

On site Nurse per hour $37.00

OSHA Respiratory Fit Test and Review:-this charge is in addition to the mask charge of $27.00

Arsenic Fractionation Test (Further Testing If Medically Indicated)

Blood Alcohol Test

Heavy Metal (Spot Urine - Arsenic/Lead/Merc/Cadmium)

Reference Lab Send-outs

Administration

Page 1 of 2

Visit https://maineurgentcare.com

/ for the latest updated form

Workers’ Compensation Injury Treatment Date of Injury: Type of Injury:

Post Accident Drug Screen Required Check Type Above Yes (send copy) NoPost Accident DOT Drug Screen Required Breath Alcohol Testing DOT (82075.D) or Non-DOT (82075.N)

Bill Employer Insurance Carrier W/C Carrier Name:

W/C Carrier Address:

W/C Carrier Phone: W/C Carrier Fax: Policy Number:

REQUIRED FOR ALL WORKERS’ COMPENSATION VISITS

Check Type Above

Bill Patient - Payment due at time of service

Name on Card:

Card Type:

Exp Date: Code:

Card Address: City: State: Zip Code:

EMPLOYERI also understand that the services provided will be paid in full by the company listed above and authorized by my signature below.

Employer Signature (REQUIRED)X

Date

Title:

Printed Name (REQUIRED)

EMPLOYEE SIGNATURE & STATEMENTI understand that I will be responsible for payment of services indicated above should circumstances arise resulting in non-payment from my employer.

Employee Signature (REQUIRED)X

LOCATION:

Date

Maine Urgent Care Team Member:

Card Number:

BILLING INSTRUCTIONSBill Established Employer Account (account must be current - no past due balance)

Visa MasterCard Discover American Express

Page 2 of 2