Transcript Houston Area Designated Test Facility Locations Northeast Deer

Employer’s Authorization
for Treatment Form
(Concentra Medical Centers)
3 Day Deadline is: __________.
Conditional Job Offer Date: ______________________________________
Start Date: ____________________________________________________
(Start date should be five (5) working days after offer date)
Employee’s Anticipated Time of Arrival for Test: ______________AM PM
Facility Location Selected (See Below): _______________
HCC Hiring Manager or Designee:
1. Do not leave any lines on this form blank. All required fields must be completed.
2. Make sure to indicate the 72 hour (3 day) deadline and inform the employee.
3. Fax the completed request form to the appropriate Concentra location immediately after conditional
job offer is made!
4. Attach request form, along with fax confirmation transmittal to employee’s paperwork.
Patient Name: __________________________ Patient Contact No.: ____________________
Employer:
Houston Community College System
Return Fax: 713-718-8567
Remind Employee
PICTURE ID
WILL BE REQUIRED
Authorized by: (Please Print) _______________________________________________________
(Hiring Manager, Dept. Chair or Designee)
Authorizer’s Title:
______________________________________________________________
Authorizer’s Signature: __________________________________________________________
Type of Service:
X Non-Regulated Drug Test (10 Panel Test Required) X Pre-Placement
X Urine Collection Only
Houston Area Designated Test Facility Locations
Northeast
Deer Park
Downtown
10909 I-10 East Freeway
Houston, TX 77029
125 E. 8th Street
Deer Park, TX 77536
2004 Leeland
Houston, TX 77003
Tel: 713-973-7943
Fax: 713-973-7947
Tel: 281-930-8555
Fax: 281-930-9870
Tel: 713-223-0838
Fax: 713-223-1310
Hours:
Monday-Friday 7AM – 7PM
Saturday
8AM - Noon
Hours:
Monday-Friday 8AM – 5PM
Hours:
Monday-Friday 8AM – 5PM
Southeast (Hobby)
8505 Gulf Freeway, Ste F
Houston, TX 77017
Tel: 713-944-4442
Fax: 713-944-4582
Hours:
Monday-Friday 8AM - 5PM
Form HCC-HR-520B