ABOUT SSL CERTIFICATES
   

Authorization For Treatment
3601 Houma Blvd., Suite 203, Metairie, LA

Monday - Friday, 9 a.m. to 5 p.m.
Physical Exams: Monday - Friday, 9 a.m. to 4 p.m.

Fields marked with an asterisk(*) are required.

General Information
Employee's Name *
Injury Date *
Injury Time *
 

Employer Information
Name *
Street Address *
City, State, Zip Code *
Phone Number *
Person Authorizing Treatment *


Reason For Visit (Please check all that apply.)
Physical Exam
      Type:
Urine Drug Test
      Federal (DOT/CDL)
      Non Federal (State)
      Reason for test:
Alcohol Test
      Screen
      Evidential Breath
      Blood
Injury
      Workers' Comp
      General Liability

Additional Testing/Comments:



Please note: Upon form completion, EJGH will forward your employee’s information to MHM Occupational Medicine. They will be providing any applicable evaluations, treatments, and return to work status letters.