Occupational Medicine Clinic  
For emergency needs contact us at
(361) 664-6504
  Vision
  Screening
  Post- Offer
  Physicals
  Functional
  Capacity Testing
  Respiratory
  Fit Testing
  Audiogram
  Testing
  Alcohol and Drug
  Screening
Home Medical Sevices Requisition Service Form Location Contact Us
No Wait Time
for 1st time injuries
Pager:
(361) 435-7823
Answering Services:
1-800-650-6735
Hours of Operation:
Monday–Friday
8:30 A.M.–4:30 P.M.
 
Requisition Service Form
OSHA Regulation Awareness for Workers' Compensation Cases and Drug Screening
      Requisition Form
Company Name:
Company Location:
Employee Name:
SSN:  (xxx-xx-xxxx)
Date:  (mm/dd/yy or mm-dd-yy)
Time Issued:  (hh:mm)
Person Authorizing Test:
Collection Site:
Type of Test(s) to be performed.
Check all applicable boxes.
DOT Drug Test
DOT Breath Alcohol
Non-DOT Drug Test
Non-DOT Breath Alcohol
Exxon/Mobil Panel
EnCana Non 10-Panel Drug
3 Panel In House Drug Screen
5 Panel In House Drug Screen 		DOT Physical
Non-DOT Physical
Functional Capacity Test
Pulmonary Function Test
Auditory Test
Fit Test - Half Full
Other Test:  
Others:
DOT Drug Screen Collection
Non-DOT Drug Screen Collection
      (Company COC Form)
Reason for Testing and DOT Entity
Check all applicable boxes.
Pre-employment
Random
Post-Accident
Reasonable Suspicion
Annual
FMCSA(CDL) 		Return to Duty
Follow-Up
Pre-Access
Recertification
RSPA -Pipeline
Other:  
 


Special Instructions: Manager, Please fax completed form to (361) 664-6531 or E-Mail to FrontOfficestcc@sbcglobal.net before the employee leaves your office, then give form to employee to take to the collection site.

For assistance contact our Drug and Alcohol Plan Administrator at (361) 664-6504.

Click here to download our Requisition Form.


Home | Medical Services | Requisition Service Form | Location | Contact Us
South Texas Cost Containment
102 E Main Street
Alice, TX 78332-4963 		Phone: (361) 664-6504
Fax: (361) 664-6531
info@southtexascostcontainment.com