Ebla's
Occupational
DOWNLOADABLE FORMS FOR PATIENTS AND EMPLOYERS
Forms sorted by category
FREQUENTLY
USED FORMS
Employer Authorization Form- We must have a completed and signed Employer Authorization form for any patient coming to Ebla's Occupational for treatment of a first time or a new energy.
Digital Telemedicine Authorization Form
Telemed Authorization Form – By filling out this form, you authorize your employee for telemedicine. After you complete the form, it will be automatically sent to Concentra. This form must be completed every time an employee uses Concentra Telemed.
Urgent Care - Patient Forms
Consumer Health Patient Information Form (English & Spanish) — You can print and complete this patient form in advance, or complete the copy provided at check in.
Employer Forms
Employer Authorization Form — We must have a completed and signed Employer Authorization Form for any patient coming to a Concentra Medical Center for treatment of a first-time or new injury.
Request for Medical Surveillance Services — Employers interested in Medical Surveillance Exams from Concentra can complete this form in preparation for a discussion with one of our experts.
Regulatory Exam Authorization Form — Employers authorizing regulatory exams such as Respirator Clearance and Medical Surveillance should complete the attached and send it in with the employee.
Other Forms
OSHA Respirator Medical Evaluation Questionnaire – Please complete and print this form before your respirator evaluation.
Baseline Asbestos Questionnaire – Please print and complete this required form before your baseline asbestos medical surveillance exam.
Periodic Asbestos Questionnaire – Please print and complete this required form before all annual asbestos medical surveillance exams following your baseline asbestos exam.
Travel Health Questionnaire – Every travel health patient obtaining a travel health consult must provide their travel itinerary, health and vaccine history prior to their consultation. Please print and complete this form prior to your visit.
DOT Physical Forms (CDL)
Medical Examination Report (MER) Form, MCSA-5875— This form is an example of what patients can expect. The MER will be completed online at the center and does not need to be printed and completed beforehand.
Medical Examiner's Certificate (MEC), Form MCSA-5876 — This form is an example of what certified drivers can expect. Certified drivers will receive their MEC after the exam is completed.
Insulin-treated Diabetes Mellitus Assessment MCSA-5870 — Commercial drivers with insulin-treated diabetes need to have this form completed by their treating clinician no more than 45 days prior to examination by a certified medical examiner (CME). This form is required before a Medical Examiner's Certificate Form MCSA-5876 can be issued to a certified driver.