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OMP – Authorization for Services
Complete this form and submit.
"
*
" indicates required fields
URL
This field is for validation purposes and should be left unchanged.
Employee's Name
*
Birthdate
*
Phone
*
Company Name
*
Expiration Date
*
Authorized By
*
Phone
*
DRUG/ALCOHOL SCREENING SERVICES
Type of Test:
DOT
Non-DOT
Instant
Breath Alcohol
Other
Other Test Type
Reason for Test:
Random
Pre-employment
Post-accident
Reasonable Cause
Return-to-Duty
Other
Other Reason
VACCINATIONS
Vaccinations
Influenza (Flu)
COVID-19
Tdap
Hepatitis B
Other
PHYSICAL EXAM
Physical Exam
Pre-employment Exam
Return-to-Work / Fitness for Duty
DOT Certification
OSHA Respirator Medical Evaluation
Other
Other Physical Exam
TB TESTING
TB Testing
PPD Skin Test
Quantiferon Gold Blood Test
INJURY TREATMENT
Date/Time of Injury
OTHER SERVICES
Other Services
Respirator Fit Test
Hearing Screening (Audiogram)
Vision Screening
Other
Other Services
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