Ascension Michigan at Work Employer Authorization For Treatment/Billing Date _________________________ Employee Name _____________________________________________________________________ Job Title/Duties ____________________________________________________________________________________________________ Employer __________________________________________________________ Phone _________________________________________ Address ___________________________________________________________________________________________________________ Street City State Zip MINORS MUST BE ACCOMPANIED BY PARENT OR LEGAL GUARDIAN Injury Care: (Describe) ______________________________________________________________________________________ a.m. Date of injury: _____________________________________________________________Time: ________________________ l p.m.l Controlled Substance Test with this injury: l Urine Drug Screen l Breath Alcohol Test Patients treated after hours in Urgent Care or Emergency Department should return for follow-up care at the nearest occupational health office. Physical Exam (bring eyeglasses and/or contact lenses and case) l Post-offer/Pre-hire l DOT—new hire l MCOLES l Annual l DOT—renewal l Preventive Well Exam l Return to Work l Hazmat l Silica Exam l Other_______________________________________________________________________________________________________ Drug and Alcohol Testing (photo identification required) l DOT Urine Drug Screen l Urine Drug Screen l Breath Alcohol lDOT Collection Only l Collection Only lDOT Breath Alcohol l Hair Testing Reason: l Pre-hire l Random l Post accident l Reasonable suspicion l Return to duty l Follow Up l Other Screening/Immunization l Audiogram l TB Test (PPD) l Lift Test l Audiogram w/Analysis l Hepatitis B Vaccination l Pulmonary Function Test (PFT) l EKG l Hepatitis B Titer l Vision Screen l Respirator Questionnaire l Travel Medicine (Rochester) l Hepatitis A Vaccination l Respirator Fit Test (No facial hair. No tobacco, food or drink (except water) one hour prior to test) l Other ______________________________________________________________________________________________________ AUTHORIZED BY: __________________________________________________________________________________________________ (Please print) Phone AUTHORIZED SIGNATURE: _________________________________________________________________________________________ ascension.org/michigan Your Partner in Workplace Health & Wellness 34030-66980-020 REV 4/30/2021 Ascension Michigan at Work Locations in SE Michigan to Serve Your Workplace DETROIT/GROSSE POINTE WOODS MADISON HEIGHTS Ascension St. John Hospital Ascension Macomb-Oakland Hospital, Madison Heights 19251 Mack Ave., Suite 100 27351 Dequindre Rd. Grosse Pointe Woods, MI 48326 Madison Heights, MI 48071 313-343-3740 • Fax: 313-343-7864 248-967-7715 • Fax: 248-967-7716 Monday - Friday 7:30 a.m. - 4 p.m. Monday - Friday 7:30 a.m. - 4 p.m. EAST CHINA NOVI Ascension River District Hospital Ascension Providence Hospital, Novi Campus 4100 River Rd. Outpatient Center, northeast entrance East China, MI 48054 47601 Grand River Ave., Suite B230 810-329-8912 • Fax: 810-329-8913 Novi, MI 48374 Monday - Friday 7:30 a.m. - 4 p.m. 248-465-4800 • Fax: 248-465-4872 Monday - Friday 7:30 a.m. - 4 p.m. HOWELL ROCHESTER Ascension Medical Center Ascension Providence Rochester Hospital 1225 S. Latson Rd., Suite 130 South entrance, second level parking structure Howell, MI 48843 1101 W. University Dr. 517-338-2370 • Fax: 517-338-2371 Rochester, MI 48307 Monday - Friday 7:30 a.m. - 4 p.m., after hours injury care 248-652-5203 • Fax: 248-652-5128 available in Urgent Care daily until 9 p.m. and holidays Monday - Friday 7:30 a.m. - 4 p.m. 11 a.m. - 5 p.m. LIVONIA SOUTHFIELD Ascension Providence Health Center Ascension Providence Health Pavilion 37595 Seven Mile Rd. 22255 Greenfield Rd., Suite 422 Livonia, MI 48152 Southfield, MI 48075 734-432-6668 • Fax: 734-542-6108 248-849-3195 • Fax: 248-849-3390 Monday - Friday 7:30 a.m. - 4 p.m. Monday - Friday 7:30 a.m. - 4 p.m. MACOMB TOWNSHIP Ascension St. John Hospital Health Center 17700 23 Mile Rd. Macomb Township, MI 48044 586-868-9120 • Fax: 586-868-9136 Monday - Friday 7:30 a.m. - 4 p.m. AFTER HOURS INJURY CARE IS AVAILABLE IN THE EMERGENCY ROOM AT ASCENSION MICHIGAN HOSPITALS.