Occupational Healthcare Services - Authorization Form - CNS Occupational Medicine

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Screenings and Tests

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DOT Drug and Alcohol Testing

Drug and Alcohol Consortium Admin Services

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DOT/Non-DOT Consulting

We offer consulting services for a number of services including DOT and Non-DOT Drug Testing. Also, you can take advantage of our online training courses at CNS Learning Hub to train your employees.

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OSHA Medical Surveillance Consulting

We offer consulting services for a number of OSHA services from Respiratory Fit Testing to Noise Surveys and Noise Abatement to best practices to protect your employees from Silica Dust. Also, you can take advantage of our online training courses at CNS Learning Hub to train your employees.

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DOT Compliance & Licensing Consulting

Compliance Navigation Specialists (CNS) is specifically focused on trucking companies and keeping them DOT Compliant. The DOT Compliance Programs make things simple for motor carriers.

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DOT/Non-DOT Consulting

We offer consulting services for a number of services including DOT and Non-DOT Drug Testing. Also, you can take advantage of our online training courses at CNS Learning Hub to train your employees.

Learn more >>>

OSHA Medical Surveillance Consulting

We offer consulting services for a number of OSHA services from Respiratory Fit Testing to Noise Surveys and Noise Abatement to best practices to protect your employees from Silica Dust. Also, you can take advantage of our online training courses at CNS Learning Hub to train your employees.

Learn more >>>

DOT Compliance & Licensing Consulting

Compliance Navigation Specialists (CNS) is specifically focused on trucking companies and keeping them DOT Compliant. The DOT Compliance Programs make things simple for motor carriers.

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CNS Companies is a network of companies specializing in services related to the transportation, manufacturing, construction, service, education and medical industries. Each division offers specific services, all related to DOT- and OSHA-regulated companies.

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How to Start an Employee Health Fair This Fall: Flu Shots, Safety, and Beyond

Fall is the perfect time for companies to focus on employee health and wellness. With flu season around the corner and the year-end safety push

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HIRING NEW EMPLOYEES? Pre-Employment Physicals are essential!

Occupational Healthcare Services: Authorization Form

Please fill out this form to the best of your ability and include any required information.

Please enable JavaScript in your browser to complete this form.

1Personal Information

2Injury Care

3Non-Injury Care

4Non-DOT Care

5DOT Care

6Other Types of Care

Company/Patient Information:

Company Name: *

Staffing Agency:

Patient Name: *

Authorized By: *

Employer Email: *

Employer Phone: *

Date: *

Select a Clinic *

INJURY CARE: Treatment/Evaluation

Are you treating an alleged work-related injury or illness? *

Yes
No

(If no, click next to skip this question)

Type of Test/Screen:

Drug Screen with initial visit
Breath Alcohol Test with initial visit

What is the type of injury or illness?

Urine (check a

NON-INJURY CARE

Is this a Non-DOT or a DOT Procedure? *

Non-DOT Procedure
DOT Procedure
Both
None of the above

NON-INJURY CARE: Non-DOT

Do you need a Non-DOT Physical Examination? *

Yes
No

What type of Non-DOT Physical Examination?

Do you need a Non-DOT Drug Test? *

Yes
No

What type of Non-DOT Drug Test? (check all that apply)

Urine
Rapid
Collection Only
Hair
Saliva
Observed

What type of Non-DOT Urine Panel?

What is the reason for the Non-DOT Drug Test?

What type of Non-DOT Rapid Panel?

What type of Non-DOT Saliva Panel?

Do you need a Non-DOT Breath Alcohol Test? *

Yes
No

What is the reason for the Non-DOT Breath Alcohol Test?

NON-INJURY CARE: DOT

Do you need a DOT Physical Examination?

Yes
No

What type of DOT Physical Examination?

Do you need a DOT Drug Test? (federally mandated)

Yes
No

What type of DOT Drug Test?

Urine
Collection Only

What is the reason for the DOT Drug Test?

Do you need a DOT Breath Alcohol Test?

Yes
No

What is the reason for the DOT Breath Alcohol Test?

NON-INJURY CARE: OTHER

What other Tests do you need?

Hepatitis B
Chest X-Ray
Pulmonary Function Test
TB Skin Test (Single)
TB Skin Test (Double)
TB Blood Test
Audio Test
Vision Test
Lift Test
Labs

Please provide any other details about your other tests:

Other testing and/or company specific instructions:

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800.551.9816
info@cnsoccmed.com
151 Koser Road
Lititz, PA 17543
20797 Professional Park Blvd.
Georgetown, DE 19947

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CNS Occupational Medicine is a Professional Company domiciled in Pennsylvania. In Delaware, CNS Occupational Medicine is referred to as CNS Occupational Medicine of Delaware Inc. CNS Occupational Health LLC is a management service company which provides services on behalf of Private Practices operating as Occupational Medicine clinic and employer on-site medical centers. The Private Practice has complete control with regards to all medical decision-making and patient care.. MSO provides consultation services and offers recommendations for the Private Practice to consider, reject, revise and/or adopt as it deems fit.