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Get Wellspan Occupational Health Employer Authorization Form 2016-2024

By (sign): Employee Name: Employee Address: Social Security Number: Email: DOB: Reason For Visit (check all that apply): Work Related Injury Physical Examination Pre placement Periodic/Annual Exposure Date of occurrence: Body part affected: Substance Abuse Testing Drug Screen Breath Alcohol Type of Substance Abuse Testing DOT NON DOT Reason for Substance Abuse Testing Preplacement Post accident Random Reasonable suspicion Follow up Other Procedures PPD HEP A Other: PPD (tw.

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