Occupational Health Authorization Form

 Occupational Health Authorization Form Please complete sections A, B and C, . Authorization required for all Emergency Room & Occ Health Visits Section A Date: _____________________ Employer/Company Name:____________________________________________ Employee or Applicant Name: ____________________________________ (Patient must have photo I.D.) Employer Representative Authorizing Service (please print) _____________________________________________ Primary phone no. of authorized representative: _______________________ Cell/Other :____________________ Complete Section B and C Section B Please indicate purpose for visit with check marks: Injury Visit: ___ Pre‐Employment ___ Suspicion ___ Follow up: ___ Return to Work Exam___ Random ___ (Drug__ Alcohol__) Fit for Duty Exam: ____ Other:____________________ If you have different protocols for various positions, please specify which position applies:_______________________ Annual or Recertification___ (please indicate which type below) DOT___ Bus Driver___ Firefighter___ Police___ Respiratory Fit:____ Other service, please specify: _____________________________________________________________________ Section C Please indicate the appropriate instructions for the above service(s) : Follow our standard company protocols for above services: ______ OR Please perform only the following services: ________________________________________________________ Signature of authorized representative:_______________________________________________________ Please Note: pre‐placement drug and alcohol testing is not performed in the Emergency Departments. 03755017 12-13
Occupational Health Clinics and Hours of Operation
Occupational Health Clinics and Hours of Operation
Centegra Occupational Health - McHenry
4309 Medical Center Drive
Medical Office Bldg, Suite B300
McHenry, IL 60050
Phone: 815-759-4224, Press "1"
Fax:
815-363-0136
Monday-Friday: 7:00 a.m. to 5 p.m.
Centegra Occupational Health - Woodstock
Route 14 and Doty Road
Next to Emergency Room
Woodstock, IL 60098
Phone: 815-759-4224, Press "2"
Fax:
815-334-3820
Monday - Friday: 8:00 a.m. to 4:00 p.m.
Centegra Immediate Care - Crystal Lake
360 Station Road,
Road Behind Dominick's
Third floor
Crystal Lake, IL 60014
Phone: 815-759-4224, Press "3"
Fax:
815-455-8044
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Sat/Sun/Holidays: 8:00 a.m. to 5:00 p.m.
Centegra Immediate Care - Huntley
10350 Haligus Road
Huntley IL, 60142
Phone: 815-759-4224, Press ""
Fax:
847-802-7112
Monday - Friday, 8:00 a.m. to 8:00 p.m.
Sat/Sun/Holidays: 8:00 a.m. to 5:00 p.m.
After Hours
Please Use Emergency Rooms:
Centegra Hospital - McHenry
4201 Medical Center Drive
McHenry, IL 60050
Phone:
815-344-5000, ext. 3100
Centegra Hospital - Woodstock
Route 14 and Doty Road
Woodstock, IL 60098
Phone:
815-338-2500, ext 3900
Please use required authorization forms when
directing employees to Emergency Rooms.
We cannot perform drug & alcohol tests
without proper authorization.