Urgent Care + TeleHealth Referral Form

Please complete this form for the UC + TH location where services are to be provided. To inquire about appointment availability or to change or cancel an appointment, please call the Clinic you are scheduled at, and ask for the OHSS service representative or a clinic staff member. Napa (707) 377-1007, Sonoma (707) 940-1001, Petaluma (707) 940-5005.

Employee should arrive at least 30 minutes early for their exam, and must bring the following:

Government-issued ID (i.e., Driver’s License, Real ID, passport)
All immunization records, if applicable and available
TB Test records, if applicable and available
Hearing aid (if applicable)

Clinic Location

Date

Phone:

Fax:

Company Name:

Dept:

Guarantor Name/Number (Internal Use):

Company Contact for results/questions:

Phone:

Email:

Fax:

Employee Name:

Address:

Home Phone:

Work Phone:

SS#: (last 4 digits only

Date of Birth:

Other Name(s) used (when applicable

Gender (Assigned at Birth):

Male

Female

Job Title:

Services Requested

Preplacement Services:

**ATTENTION: Unless previously submitted, a job description is required at the time of the exam to avoid a delay in medical clearance.**

(PP2) PRE-PLACEMENT EXAM – ALL JOBS (EXCEPT FOR THOSE IDENTIFIED IN THE OTHER PRE-PLACEMENT EXAM CATEGORIES)

Standard Service(s): Pre-placement Exam Fee $190

(DISPATCH) PUBLIC SAFETY DISPATCHER PRE-PLACEMENT EXAM

Fee 294

Drug Screen: Non-DOT 5 Panel: $52

Standard Service(s): Pre-placement Exam, Audiogram Fee $294

(POSTPP) POLICE/SHERIFF PRE-PLACEMENT

Fee $1,234

Drug Screen: Non-DOT 5 Panel: $52

Fee for package: $1,234 not including cardiac testing Standard Service(s): POST Physical Exam, Audiogram, EKG (Resting), Cardiac Stress Test w/Treadmill, PPD 1-step, Chem Comp Panel, CBC/diff, Titers: Hep B Surface / Hep B Core / Hep C / Hep A, Venipuncture

(DRUG) URINE DRUG AND BREATH ALCOHOL TESTING (STANDALONE FOR NEW HIRES)

Non-DOT 5 Panel: $52

Non-DOT 10 Panel(RTW): $69

Breath Alcohol Testing (BAT): $144

Standard Service(s): Collection for Drug Screen

(PPD/TB) TB CLEARANCE (STANDALONE FOR NEW HIRES)

PPD 1-step: $69

QuantiFERON: $334

Standard Service(s): PPD 1-step OR QuantiFERON

(VAX) VACCINATION ONLY (STANDALONE FOR NEW HIRES)

Standard Service(s): History/Review of Tests/Brief Screen -No Phys Exam

Non-Pre Placement Services:

(PPD/TB) TB CLEARANCE

(DMV) DMV/DOT EXAM

Standard Service(s): (DMV/DOT Physical Exam $190

(RESP) RESPIRATOR CLEARANCE - BASELINE OR PERIODIC

Standard Service(s): Review of OSHA Respirator Questionnaire by MD/NP/RN $110

(AUDIO) AUDIOGRAM

Standard Service(s): Audiogram $104

(VAX) VACCINATION ONLY

Standard Service(s): History/Review of Tests/Brief Screen - No Phys Exam

Standard Service(s): PPD 1-step OR QuantiFERON

PPD 1-step $69

QuantiFERON $334

(DRUG) URINE DRUG AND BREATH ALCOHOL TESTING

Non-DOT 5 Panel: $52

Non-DOT 10 Panel(RTW): $69

Breath Alcohol Testing (BAT): $144

(FFD/RTW) FITNESS FOR DUTY/RETURN TO WORK

Standard Service(s): Fitness for Duty Physical Exam *Prior to scheduling the evaluation, the employer will coordinate with UC + TH staff to obtain, as available, certain documentation and any medical records to review.

Standard Service(s): History/Review of Tests/Brief Screen - No Phys Exam, Venipuncture

Other services may be provided and billed at the physician/clinician’s discretion to give clearance on an applicant/employee as identified in your Letter of Agreement (LOA) under the “As Clinically Indicated” section of that visit category. If other screening/testing is needed and is not outlined in the LOA, we will call for authorization.

SCHEDULE APPOINTMENT WITH

Applicant/Employee (and notify employer)

Employer

Preferred date and/or timeframe for appointment:

APPT IS SCHEDULED FOR:

Comments/Additional Requests:

Fax/email appt back to the department contact noted above?

"For Clinic Use Only"

1st attempt for notification to employee: Date: Time:

Initials:

2nd attempt for notification to employee: Date: Time:

Initials:

3rd attempt for notification to employee: Date: Time:

Initials:

MA inital and date rec’d:

Pt Chart #:

Confirm clinic:

Total

Napa: (707) 377-1007

Benicia: (707) 377-1005

Sonoma: (707) 940-1001

Petaluma: (707) 940-5005

Workers Comp: (707) 750-5402

Napa: (707) 377-1007

Benicia: (707) 377-1005

Sonoma: (707) 940-1001

Petaluma: (707) 940-5005

Workers Comp: (707) 750-5402

Services Requested