1430 W. 7th Avenue

CORSICANA, TEXAS 75110

Phone (903) 872-1880

Fax (903) 872-1917

MEDICAL TREATMENT AUTHORIZATION

REASON FOR VISIT—CHECK ALL THAT APPLY

1 Pre-Employment                 1 Re-Cert                  1 Random                 1 Reasonable Suspicion / Cause 

q    Non-DOT Drug Screen                 q DOT Drug Screen                          q Spirometry

q    Non-DOT Physical                        q DOT Physical                                 q Breath-Alcohol

q    Post Accident / Follow-Up             q DOT Breath-Alcohol                 q Hearing Screen

q    Return-to-Duty                               q Work Injury  -  Date of Injury ____________________   

q    WorkSTEPSâ       ________________                         q Other ________________________

                                                ^{Job Specific}

Employer _____________________________________________ Phone ______________________________

 Address ______________________________________________   Contact _____________________________

WE AUTHORIZE ENVIVA HEALTH SERVICES, PA TO EVALUATE ____________________________________

                                                                                                                                (Employee’s Name)

Please Check Appropriate Box: Deliver Physicals/Test results by:

            1Mailed  1Fax  1Phone  1Delivered by Patient  1E-Mailed: _____________________________