Patient's
Name_______________________________________________________
Patient's Complaint
___________________________________________________
Patient's Job Duties _________________________ Date of
Injury/Illness ________
Referred By:
______________________________________________________
Substance Abuse Screening Policy Testing
Consent Agreement & Medical Authorization
Company substance abuse policy requires
post-accident substance testing when an injury/illness becomes OSHA
recordable or medical treatment other than first-aid is required.
By my signature below, I hereby certify and
agree as a condition of my employment and continued employment that:
- I have personally read (or had read to
me), understand and will comply with all provisions set forth in the
Substance Abuse Screening Policy as presented to me, including this
consent to be tested.
- I understand that failure to comply with
and/or honor of the terms of this policy is sufficient cause for
termination of my employment.
- A photocopy of this consent form will
serve in it's stead as an original authorization document regardless of
the date signed.
By my signature below, I hereby consent to,
and by this Authorization, or any photocopy hereof, authorize the release to
my employer or any other agent or employee of the company by any hospital,
medical clinic, surgeon, physician, pharmacist or any other provider of
medical services, treatment or supplies all medical reports, histories,
findings, prognosis, bills, information and other documents relating to any
medical treatment, hospitalization, prescription drugs or other medical
service or supplies, including psychiatric treatment or treatment for
alcoholism or drug abuse provided to or utilized by myself.
Employee Signature
_______________________________ Date ____________
Reader/Interpreter Signature
_______________________________ Date
______________
______________________________________________________________
Medical Provider: please
provide the following information
Please Call {INSERT JOB
TITLE} at XXX-XXXX, Extension XXXX
if you need further
information or need to relay information concerning this patient.
Date _______________ Time In _______________
Time Out _____________
Diagnosis
_____________________________________________________________
Treatment Plan
________________________________________________________
Return Appointment?
q Yes
q
No Date ___________ Time __________ am/pm
Referred to: Dr. __________________ Date
___________ Time ___________am/pm
Continued on reverse side
F
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Work Release
Modified work, other than
the patient's regular job may be available. To assist in restoring the
patient's regular work and pay, please complete the information below
q
No Duty from ______________ to _______________
q
Modified Duty from ______________ to _______________
q
Return to Full Duty on ___________
Modified Duty Limitations Physical
Limitations
q
No prolonged standing ___________________________________________
q
No prolonged walking ____________________________________________
q
No prolonged sitting
______________________________________________
q
No knee bending, squatting, kneeling
_______________________________
q
Limited or no use of
______________________________________________
q
Weight lifting restrictions
__________________________________________
q
Keep affected area elevated
_______________________________________
q
Keep dressing dry and clean
_______________________________________
q
Use crutches/sling/splint
___________________________________________
q
Other _________________ ________________________________________
List of prescribed medication and
frequency of directed use
_____________________________________________________________________
Prescribed therapy and frequency
_____________________________________________________________________
Physician Comments:
_____________________________________________________________________________
Physician's Signature
_______________________________________________
By my signature, I have read, or had read to me, and
fully understand the work restrictions as listed by the Physician.
Patient's Signature ____________________________
Date ____________
Reader/Interpreter Signature
_________________________ Date ______________