Texas Med Clinic New Account Set-Up Form Page 4
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New Account Set-Up Form | CONTACTS
Fax: 210.471.0217 | email:
Yes, our company requires employees to bring this form
Treatment Authorization Form:
No, our company does not require this form.
A form used by employers to indicate which services are needed. This form can be Texas MedClinic’s Treatment authorization form
or this can be your own company’s authorization form. This form will override all services on your protocol and only the ser-
vices selected on this form will be performed by the clinic.
Occupational Results
Main Contact
Drug Tests
X-rays
Respirator Fit Test
Breath Alcohol Tests
Name:
TB Tests
Hearing Test
Physicals
Copy of CCF
PFT/Spirometry
Immunization/Titers
Vision Test
Phone:
Work Related Injuries
Receives Work Status Reports
Fax:
Will Authorize Services for Work Related Injury treatment
After hours contact for injuries
Email:
Cell Phone:_______________________________________
Will Authorize Services if no Treatment Authorization Form is provided
Other: _________________________________________________________________________________________
Occupational Results
Additional Contact
Respirator Fit Test
Drug Tests
X-rays
Hearing Test
Breath Alcohol Tests
Name:
TB Tests
PFT/Spirometry
Physicals
Copy of CCF
Vision Form
Immunization/Titers
Phone:
Work Related Injuries
Receives Work Status Reports
Fax:
Will Authorize Services for Work Related Injury treatment
Email:
After hours contact for injuries
Cell Phone:_______________________________________
Will Authorize Services if no Treatment Authorization Form is provided
Other: _________________________________________________________________________________________
Occupational Results
Additional Contact
Drug Tests
Respirator Fit Test
X-rays
Breath Alcohol Tests
Hearing Test
Name:
TB Tests
Physicals
PFT/Spirometry
Copy of CCF
Immunization/Titers
Vision Test
Phone:
Work Related Injuries
Fax:
Receives Work Status Reports
Will Authorize Services for Work Related Injury treatment
Email:
After hours contact for injuries
Cell Phone:_______________________________________
Will Authorize Services if no Treatment Authorization Form is provided
Other: _________________________________________________________________________________________
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