Service Provider Medical Center

Location:

Bensalem, PA

Posted:

May 18, 2024

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Resume:

*AI***********

AI**********

Instructions for Service Provider

Please proceed to the following location:

Concentra Medical Center - Plymouth Meeting

*** ********** ****

PLYMOUTH MEETING, PA 19462

610-***-****

Providers with eScreen123 must scan ePassport into eScreen123. Use eScreen Scheduled Event Account. Scan this barcode into eScreen123®

Instructions for Calvin Clark

Participant ID:

Account: 132863-4

Honor

This order must be completed by:

7/28/2023 10:59 PM (ET)

Account Type: National Account

Phone:

Note: Completion time displayed does not mean that the service provider is open until the time shown. Note: Please call service provider for operational hours and to schedule an appointment or visit the service provider’s website for hours of operation. Bill services to: eScreen, Inc., PO Box 25902,

Overland Park, KS 66225

• You are required to take a photo ID,

this ePassport, and all documents with

which it printed.

• If you are under 18, a parent or legal

guardian may be required in order for

services to be performed. Verify with

the service provider before arriving.

Fax: 610-***-****

Services(1):

Regulation: NON-DOT

Reason for Test: Pre-employment

Reason for Service: Pre-employment

Services(1):

1. Urine Collection - 2349 -

8DSP/PHN (2349)

1. TB/PPD Test 1

Instructions:

Take all documents that print with this packet of information to the clinic. Applicant/Employee Name:

Confirmation Number:

eScreen Account Info:

eScreen Site ID:

Clark, Calvin

AI7973147595

132863-4

4324 - Concentra Medical Center - Plymouth Meeting Please Note: The information on this document is specific to a single event. To ensure timely and accurate reimbursement for the services, please use this information only for the applicant referenced above. AI7973147595

AI7973147595

Medical Services:

1. TB/PPD Test 1 : TB TEST MUST BE READ WITHIN THE 48-72 HOUR TIME FRAME FOLLOWING THE

INJECTION. PLEASE MAKE NOTE OF THE

EXACT TIME THE INJECTION WAS GIVEN AND

DO NOT RETURN UNTIL IT HAS BEEN A

MINIMUM OF 48 HOURS. THIS WINDOW OF

TIME IS SPECIFIC - EVEN ONE MINUTE BEFORE

OR AFTER THE 48-72 HOURS WILL CAUSE AN

INVALID RESULT AND THE TEST WILL HAVE TO

BE REPEATED.

Clinic #: 4324 eScreen Account #: 132863-4 Confirmation AI7973147595 Clinic #: 4324 eScreen Account #: 132863-4 Confirmation #: AI7973147595

[ ] TB/PPD Test 1 - Use the documents with the Passport to record the administration and results of the TB/PPD skin test. If Donor reports a previous positive result or skin sensitivity and needs a Chest Xray, please direct them to contact eScreen Medical Surveillance Department. Administer TB/PPD Skin Test 1 and Provide the attached TB Skin Test Reminder form to the Donor with the DATE/TIME for the results reading. TB test MUST be read within the 48-72 hour time frame. If the patient returns before 48 hours please instruct them to wait or come back after it has been a minimum of 48 hours from the time of injection. The 48-72 hour time frame is exact - even one minute before or after will be marked as an invalid result. Clinic Instructions:

Please follow standard protocol unless specified for the services listed below. Applicant/Employee Name:

Confirmation Number:

eScreen Account Info:

eScreen Site ID:

Clark, Calvin

AI7973147595

132863-4

AI7973147595

If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123 software.

This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed. Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the eScreen123 Follow-Up tab or fax completed documents to 913-***-****. Please fax ORIGINAL FORMS ONLY. Copies/carbons/scanned images/highlights are often illegible upon receipt. Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly. Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the instructions.

If any occupational health service(s) are requested in addition to the services listed, please call 1-800-***-****, option 5 for approval/direction.

Clinic Instructions Page 1 Of 2

Clinic Instructions:

Please follow standard protocol unless specified for the services listed below. Applicant/Employee Name:

Confirmation Number:

eScreen Account Info:

eScreen Site ID:

Clark, Calvin

AI7973147595

132863-4

AI7973147595

If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123 software.

If any occupational health service(s) are requested in addition to the services listed, please call 1-800-***-****, option 5 for approval/direction.

BILLING INFORMATION:

Invoices for services must include the eScreen account information and SSN/ID or confirmation number (as listed above) for the patient. Direct all invoices to eScreen at: eScreen, Inc.

Attn: Accounts Payable

PO Box 25902

Overland Park, KS 66225-5902

Incomplete medical service forms will not be reported, and the reimbursement will not be issued until all required information has been received by eScreen. If you have any questions, please contact eScreen at 1-800-***-****, option 5 Clinic Instructions Page 2 Of 2

eScreen

7500 W. 110th Street, Suite 500

Overland Park, KS 66210

phone 800-***-****

Revised 04/18/2016

TB Skin Test Record – Two Step

Upload in eScreen123 or Fax to eScreen after both placement and read

First Name: Last Name: Employee ID/SSN#

TB Skin Test Placement:

Step One Placement Step Two Placement

Do not proceed with Step Two if Step One was positive Date of Placement: Time of Placement: AM/PM (please circle) Manufacturer: Lot # : Expiration Date:

LEFT FOREARM (0.1 ml) RIGHT FOREARM (0.1 ml)

Administered By: Clinic Name\Address:

TB Skin Test Read: (MUST BE READ 48-72 HOURS AFTER PLACEMENT) Date of Read: Time: AM/PM (please circle)

Induration: mm (Please record in millimeters)

RESULT: NEGATIVE POSITIVE Donor failed to return for read Read By:

If Positive, contact Alere eScreen for permission to proceed with CXR If clinic performing read is different from clinic that performed placement, please list: Clinic Name\Address: Site ID:

If completing One Step read, advise donor that Step Two will need to be performed within 7-14 days. A new ePassport will be issued by the employer and given to the donor.

Contact Alere eScreen with questions: 800-***-****, option 5 Clinic #: 4324 Confirmation #: AI7973147595

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