MeDICAL CLIENT INFORMATION FORM

For Company DER, fill up below!

COMPANY FORM

Medical Client Information Form

COMPANY INFORMATION:

REPORTING OF OCCUPATIONAL TESTING:

Notes on Reporting Issues: 

Designated Employer Representatives may have the same authority or different depending on which is marked above. Please make sure that Rio Plex Safety Council will only allow medical results to be given to the Designated Employer Representative(s) that are marked on this form.


OCCUPATIONAL TESTING REQUIRED


Drug & Alcohol Collections:

□ DISA, Inc. 

□ Forward Edge 

□ ASAP Drug Solutions 

□ One Source Toxicology (Non Consortium)

□ Breath Alcohol Test

□ Instant Drug Screen (Rapid 5 Panel) 

□ Instant Drug Screen (Rapid 10 Panel) 

□ Hair Follicle Test



Occupational Health Services:

□ Respiratory FIT Testing (FIT)

□ Pulmonary Function Testing (PFT)

□ Audiometric Testing


Classroom OSHA Training

□ Supplied Air Training

□ Bottle Watch Training

Note: Each employee must have an “Authorization Form” filled out and sent to Rio Plex Safety Council prior to any testing being conducted. If you do not have a copy of this form please contact Tiffany Northrup at 956-928-1967


BILLING INFORMATION

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