Employer Forms

Providing your employees high-quality care and helping you maximize efficiency

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Employer Forms

Below you will a list of all available employer forms. If you have any questions, please contact us here.

Audiogram Questionnaire

Required for employees who require an audiogram

Authorization to Disclose Protected Health Information to Employer

Employee release to Employer

DOT Long Form (MCSA 5875)

Driver history and physical

DOT Medical Examiner Certificate (MCSA 5876)

Driver medical examiner certificate

Respirator Questionnaire (English)

Required annually for employees wearing tight fitting respirators. Recommended for those who wear loose fitting respirators.

Respirator Questionnaire (Spanish)

Required annually for employees wearing tight fitting respirators. Recommended for those who wear loose fitting respirators.

Service Authorization

Required for all employer services

Service Request

Fill out the easy form below for an employer service request.
Constant Contact Opt-In
Schedule Visit
Virtual Visit