Follow the steps to complete the service request form

1. Click ‘Get Form’ button to obtain the form and open it for online completion.
2. Begin by filling out the ‘Employer’ section, ensuring that you provide the company name and the employer's approval where indicated.
3. Next, enter the ‘Employee Name’ as it appears on their identification. This is crucial for accurate record-keeping.
4. In the ‘Appointment Date’ field, select or enter the date the appointment is scheduled.
5. If applicable, indicate the Third Party Administrator (TPA) in the provided space.
6. Select the type of drug screen being requested and ensure you indicate whether it is a DOT or non-DOT test by marking the appropriate box.
7. If the appointment involves immunizations, provide necessary details about the vaccines, including any previous injection history and related dates.
8. For ‘Walk-in Services,’ check all applicable services, and provide additional information as needed.
9. If you are requesting services by appointment only, indicate your choices and provide any special instructions or requests in the designated area.
10. After filling out all sections, review the form carefully to ensure all information is accurate before finalizing.
11. Once you have completed the form, save your changes. You may then download, print, or share the completed form as required.

Complete your Legacy Health BHS Service Request Form online today for a streamlined process.