occupational treatment authorization - texas medclinic...clinic medical director: laura perez, md...
TRANSCRIPT
\\vmstorage\MKTShare\Forms\FinalForms\OCC TA Updated 7/2/2019
*Employee will be evaluated to determine if he/she can perform the functions of the job. A written or verbal job description will be used at Physician’s discretion. ** Silica Exams Only - Services will take more than one day to complete and are only performed at selected locations ***Must bring mask & performed at selected locations only
Urgent Care | Occupational Medicine Open Everyday 8am –11pm | Select Locations Open 24 Hours
www.texasmedclinic.com
PHYSICALS Post Offer Physical*
Job Description On File Job Description Provided
DOT Physical
Respirator Physical
Hazardous Waste Physical
Asbestos Physical Initial Periodic Silica Dust Exams** (Includes: TB test, Chest X-Ray, Spirometry & Physical)
ANCILLARY TB test
X-ray authorized for TB Test if needed (Physician Evaluation Required)
T-Spot Blood Test
Audiogram
Spirometry
Respirator Fit Test***
Functional Ability Test (If authorized on company profile)
Vision Test
COMMENTS/ADDITIONAL SERVICES:
DRUG/ALCOHOL TESTING
Reason for Testing
Pre-Employment
Post Accident
Random
Reasonable Suspicion
For Cause
Follow -Up (DOT Only)
Return to Duty (DOT Only)
Other: _______________
Occupational Treatment Authorization
Company Name: ______________________________________________________ Employer ID # _________________ Address: ____________________________________________________________Store # ________________________ Phone: ____________________________________ After Hours Phone: ______________________________________ Person Authorizing (Please Print): ________________________________________________ Title: ________________ Authorization Expires on Date:_______________________________ Time:___________________________________
Employee Name: ________________________________________________________________________________
Job Title: ____________________________ Social Security #: ______________________ DOB:_________________
Electronic (Form Fox)
Employee will hand carry
Forms on file at clinic
Chain of Custody Form
RAPID DRUG TESTING
5 Panel
10 Panel
Non-DOT - Texas MedClinic lab only. Same day
negative results before 2 pm. Specimens requiring
further testing can take 2-7 business days depending
on results and date/time of collection.
BREATH ALCOHOL TESTING
Non-DOT
DOT
NON-DOT DRUG TESTING
5 Panel
10 Panel
Hair Drug Test
DOT DRUG TESTING
DOT Drug Test
FMCSA
FAA
FRA
FTA
PHMSA
USCG
DOT Testing Agency DOT Testing Authority
DOT
HHS
NRC
DISA
CMI
HireRight
Consortium/Third Party Administrator
Onsite Services
FleetScreen
Other: _____________
MMR
Varicella
Flu Shot
Other: __________
IMMUNIZATIONS
Hepatitis A
Hepatitis B
Varicella
MMR
Other: ____________
TITERS
Hepatitis A
Hepatitis B
Td
Tdap
*OCCTA*
Updated 7/29/2019
WURZBACH IH10 W/ Wurzbach (24 Hour) 9885 IH-10 West San Antonio, TX 78230 Ph: (210) 696.5599 Fx: (210) 699.8152 Clinic Manager: Jessica Elizondo Clinic Medical Director: James Bugg, MD [email protected]
CULEBRA Loop 1604 / Culebra (24 Hour) 6530 W Loop 1604 N San Antonio, TX 78254 Ph: (210) 476.5577 Fx: (210) 688.9334 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: John Cantu, MD [email protected]
FORUM IH 35 N / Loop 1604 (24 Hour) 8341 Agora Pkwy San Antonio, TX 78154 Ph: (210) 659.5533 Fx: (210) 659.7755 Clinic Manager: Dan Sookchan Clinic Medical Director: James Murray, MD [email protected]
LEON SPRINGS IH 10 W / Leon Springs 23611 IH 10 West • San Antonio, TX 78257 Ph: (210) 698.6617 | Fx: (210) 698.6627 Clinic Manager: Eddie Thomas Clinic Medical Director: Clayton Pullin, MD [email protected]
EISENHAUER IH 35 N / Eisenhauer 7460 IH 35 North • San Antonio, TX 78218 Ph: (210) 655.5529 | Fx: (210) 655.5504 Clinic Manager: Jenny Lopez Clinic Medical Director: Angela Scalzi, MD [email protected]
BLANCO Blanco / Parliament 11811 Blanco Road • San Antonio, TX 78216 Ph: (210) 341.5588 | Fx: (210) 341.7513 Clinic Manager: Ernest DeLao Clinic Medical Director: James Bugg, MD [email protected]
BROADWAY Loop 410 / Broadway 1007 NE Loop 410 • San Antonio, TX 78209 Ph: (210) 821.5598 | Fx: (210) 829.0125 Clinic Manager: Jenny Lopez Clinic Medical Director: James Murray, MD [email protected]
SOUTHEAST SE Military / Roosevelt 1111 SE Military • San Antonio, TX 78214 Ph: (210) 927.5580 | Fx: (210) 927.2700 Clinic Manager: Diana Barajas Clinic Medical Director: Brian Raimondo, MD [email protected]
BANDERA Loop 1604 / Bandera 9207 N Loop 1604 West • San Antonio, TX 78249 Ph: (210) 695.4884 | Fx: (210) 695.4949 Clinic Manager: Eddie Thomas Clinic Medical Director: Jeffery Weaver, MD [email protected]
INGRAM Ingram/Loop 410 6570 Ingram Road • San Antonio, TX 78238 Ph: (210) 520.5588 | Fx: (210) 522.1125 Clinic Manager: Ernest Delao Clinic Medical Director: Paula Lyons, MD [email protected]
STOTZER Hwy 151 / Loop 410 8519 State Hwy 151 • San Antonio, TX 78245 Ph: (210) 682.5577 | Fx: (210) 647.5566 Clinic Manager: Ann Bartolett-Gonzalez Clinic Medical Director: Joseph Elizondo, MD [email protected]
STONE OAK 1604 / Stone Oak Pkwy 323 N 1604 West • San Antonio, TX 78232 Ph: (210) 549.5893 | Fx: (210) 549.5894 Clinic Manager: Shannon Fletcher Clinic Medical Director: Paula Lyons, MD [email protected]
Locations | San Antonio/New Braunfels
SOUTHWEST SW Military / Zarzamora 2530 SW Military Drive • San Antonio, TX 78224 Ph: (210) 476.5599 | Fx: (210) 455.9217 Clinic Manager: Diana Barajas Clinic Medical Dir: Brian Raimondo, MD [email protected]
NEW BRAUNFELS IH 35 N / Hwy 46 958 IH 35 North • New Braunfels, TX 78130 Ph: (830) 606.5533 | Fx: (830) 606.5535 Clinic Manager: Destiny Cortez Clinic Medical Director: Ami Beshay, MD [email protected]
OAK RUN Hwy 46/Oak Run Pkwy 1922 S State Hwy 46 W • New Braunfels, TX 78132 Ph: (830) 632.5092 | Fx: (830) 632.5094 Clinic Manager: Destiny Cortez Clinic Medical Director: Laura Perez, MD [email protected]
Locations | Austin/Round Rock
SOUTHPARK MEADOWS IH 35 S / Slaughter Lane 9900 South IH-35 • Austin, TX 78748 Ph: (512) 291.5577 | Fx: (512) 291.5576 Clinic Manager: Julie Koenning Clinic Medical Director: Glenda Peters-Do, MD [email protected]
ROUND ROCK IH 35 N / Bass Pro Drive 4851 N IH 35 • Round Rock, TX 78664 Ph: (512) 486.6140 | Fx: (512) 863.4285 Clinic Manager: Kelly Bilsky Clinic Medical Director: Kristen Kocurek, MD [email protected]
PARMER N MoPac / Parmer 12319 N MoPac Expy • Austin, TX 78758 Ph: (512) 835.5577 | Fx: (512) 836.0166 Clinic Manager: Juanita Peka Clinic Medical Director: Kristen Kocurek, MD [email protected]
SINGING HILLS Hwy 281/Hwy 46 426 Singing Oak • Spring Branch, TX 78070 Ph: (830) 632.5740 | Fx: (830) 632.5743 Clinic Manager: Shannon Fletcher Clinic Medical Director: Angela Scalzi, MD [email protected]