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Substance Abuse Non-Dot

Location:
Byram Center, NJ
Salary:
21.00 hr.
Posted:
July 22, 2024

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Resume:

EMPLOYER'S AUTHORIZATION FOR EXAMINATION OR TREATMENT

(MUST PRESENT PHOTO ID AT TIME OF SERVICE)

Patient Name: CDL #:

Company Name: NATIONAL DCP

Address: **** ********* ****, # ***

Date of Birth:

City, State, Zip: DULUTH, GA 30096

*SUBSTANCE ABUSE TESTING*

NOTES TO CLINIC:

• QUEST LAB ACCOUNTS

DOT: 65134610

Non-DOT: 65134611

• Fax MRO Copy to 801-***-****, mail original

SUBSTANCE ABUSE TESTING AUTHORIZED:

Non-Regulated Urine Collect ONLY (use Quest Account) Regulated FMCSA Urine Collect ONLY (use Quest Account) Breath Alcohol Test: DOT Non-DOT

(Please fax all Breath Alcohol Results to CMCA at 603-***-****) REASON FOR TEST:

Pre-Employment

Random

Post-Accident

Reasonable Cause

Follow-up

Return to Duty

Other

Observed Collection: Yes No

TPA: Bill TPA for substance abuse components only

Concentra/CMCA/33014

118 Portsmouth Avenue,

Suite B202 Stratham, NH 03885

1-800-***-****

LAB:

Quest Diagnostics

10101 Renner Blvd.

Lenexa, KS 66219

MRO:

Michael Suls, DO

1430 South Main St, Ste. C

Salt Lake City, UT 84115

Ph: 888-***-****

Fax: 801-***-****

Designated Employer Representative:

DER: Jackie Jackson

Phone: 770-***-****

Secondary Contact: Shelia Gleason

Phone: 770-***-****

ADDITIONAL SERVICES:

DOT Physical - New Medical Card

Recertification DOT Medical Card

Injury Care Date of Injury:

RESULTS AND COMMUNICATION:

ALL PHYSICAL AND HPE RESULTS ARE TO BE

REPORTED TO JACQUELINE JACKSON VIA FAX AT

770-***-****

Employer copy of the chain of custody and BAT

results Fax to Employer at 770-***-****

*NOTE TO DONOR*

Please call in advance to schedule appointment for Physical and HPE's. Wear sneakers and comfortable clothing for HPE CMCA Form Revised 3/31/2021

**Bill Employer Directly**

Send all claims to Sedgwick

Employee ID:

7/17/2024

Paul Dickerson



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