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Get MedExpress Employer Authorization Form

Signature: Injury/Accident Phone: Injured Body Part: Date of Injury: Please provide the above patient with the following services: (Please check all that apply) Drug and/or Alcohol Testing (Please check type and reason below) PLEASE SELECT EITHER OPTION 1 OR OPTION 2 OPTION 1: Using MedExpress lab and MRO Breath Alcohol Test - Please check: DOT or OPTION 2: Using your company paperwork, lab, and MRO Non-DOT DOT Urine Drug Screen (5-panel) Please check one: FMCSA FAA FRA FTA .

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