Employment Medical Evaluation Results Request Form
Submit this form to request access to employment-related medical evaluation results. Complete all sections to ensure timely processing.
Requester Full Name
*
First Name
Last Name
Requester Email Address
*
example@example.com
Requester Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Requester Relationship to Employee/Patient
*
Please Select
HR/Employer Representative
Healthcare Provider
Employee/Patient
Legal Representative
Other
Employee/Patient Full Name
*
First Name
Last Name
Employee/Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Employer/Organization Name
*
Specific Evaluation Results Requested
*
Pre-employment Medical Exam Results
Return-to-Work Clearance
Drug/Alcohol Screening Results
Workplace Injury Evaluation
Immunization/Vaccination Records
Other
Preferred Delivery Method
*
Secure Email
Fax
Mail
Pick Up in Person
Submit Request
Should be Empty: