Treatment AuthorizationPlease call and speak with the receptionist before employee is sent.

Patient Time Left amName: Company: pm Date:

Company: Phone #: ( )

Work Address: City: State: Zip:

Authorized by: Date: (Supervisor of designated employee representative) Signature Print Name

Phone Number: ( )

By signing this authorization the above referenced company acknowledges and agrees that it is fiscally responsible for all incurredcharges, whether work-related or non-work-related. Charges may be submitted to the above referenced company’s Workers’Compensation carrier at the company’s discretion, but failure to submit charges to the Workers’ Compensation carrier does not relievethe company of the responsibility for these charges.

Verbal Authorization VerbalGiven By: Taken By:

WORK-RELATED INJURY/ILLNESS EVALUATION AND TREATMENTSpecific body part

DRUG OR ALCOHOL SCREEN (Photo ID Required):DRUG oDOT (5 Panel) o5 Panel ALCOHOL oDOT

oNon-DOT o10 Panel oNon-DOT

o Urine o Post-offer o Breath o Post-offero Hair o Post Accident/Initial Injury o Post Accident/Initial Injuryo Rapid Urine (Non-DOT only) o Random Test o Random Testo eScreen (Non-DOT only) o Suspicion/Cause o Suspicion/Cause

o Other o Other

PHYSICAL EVALUATION: o POST-OFFER or o ANNUALo Physical Exam o DOT Exam o Independent Medical Exam (IME) o Return to work / Fit for dutyo Respiratory Clearance oOther, please specify

SPECIFY ADDITIONAL TEST REQUIRED:o Audiogramo Pulmonary Function Testo Lab Work, please specifyo Fit for Duty by Therapisto Functional Capacity Evaluation (FCE)o Immunizations: o Hep A oHep B oPPD o Other o Respiratory Fit Test (Please call WorkHEALTH in advance to schedule)o Other Test (specify)

- over -

SSM WorkHEALTH - HAZELWOOD 637 Dunn Road, Suite 100 Hazelwood, MO 63042 Phone: 314-731-WORK (9675) Fax: 314-731-2522 Hours: 8:00 a.m.-5:00 p.m.

SSM WorkHEALTH - MID COUNTY 2321 B McCausland Ave. St. Louis, MO 63143 Phone: 314-645-WORK (9675) Fax: 314-645-1559 Hours: 8:00 a.m.-5:00 p.m.

After Hours, (5:00 p.m. - 8:00 p.m.) Contact the Urgent Care

SSM Urgent Care-St. Peters SSM Urgent Care-Maryland Heights SSM Urgent Care-Brentwood SSM Urgent Care-St. Charles 1475 Kisker Road 2022 Dorse Village 8820 Manchester Road 1551 Wall Street St. Charles, MO 63304 Maryland Heights, MO 63043 Brentwood, MO 63144 St. Charles, MO 63303 (In St. Joseph Medical Park) (Next to Schnucks) (In Schnucks Plaza) (East of Sam’s at Zumbehl) 636-498-7400 314-590-0520 314-963-8100 636-669-2211

A r hours, contact the Emergency Department at:

SSM DePaul Health Center 12303 DePaul Drive Bridgeton, MO 63044 314-344-6360

SSM St. Joseph Health Center 300 First Capitol Drive St. Charles, MO 63301 636-947-5111

SSM St. Joseph Health Center-Wentzville 500 Medical Drive Wentzville, MO 63385 636-327-1101

SSM St. Joseph Hospital of Kirkwood 525 Couch Avenue Kirkwood, MO 63122 314-966-1528

SSM St. Joseph Hospital West 100 Medical Plaza Lake St. Louis, MO 63367636-625-5300

SSM St. Mary’s Health Center 6420 Clayton Road St. Louis, MO 63117314-768-8360