Substance Abuse Non-Dot
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
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
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
Contact this candidate