OMP Consent for Services

I voluntarily consent to medical care provided by Occupational Medicine Physicians, which may include diagnostic tests, procedures, or treatments as prescribed by my physician or advanced practice registered nurse. I understand that no guarantees have been made regarding the outcomes of this care.

I consent to provide breath, blood, hair, or urine samples for alcohol and/or drug testing, and I authorize these samples to be sent to a laboratory for analysis if necessary. I understand that refusal to submit to testing may result in consequences with my employer, potential employer, or applicable government agencies.

I acknowledge that I may receive services from physicians or healthcare providers who are not employees of Occupational Medicine Physicians, such as radiologists. I agree that Occupational Medicine Physicians is not responsible for the actions of these non-employees. I authorize Occupational Medicine Physicians and my treating provider to disclose information regarding my treatment or test results to my employer, potential employer, or insurance carrier as appropriate, including the DOT medical examination form (MCSA-5875). I acknowledge that I have received a copy of the Privacy Practices notice.

Telehealth Consent
I understand that telehealth allows me to consult with healthcare providers remotely via electronic communication. I have the right to decline telehealth services and request an in-office visit. My provider may determine that an in-office visit is necessary for appropriate care. I agree that telehealth may be used when mutually agreed upon by me and my provider. I may discontinue telehealth at any time, including during a telehealth visit, and request an in-office visit if preferred.