Attention Clinic:

Time Sensitive DS Collection

This is a Priority Exam - Time Sensitive, due to the nature of the
employee's position, WorkCare must clear this employee for work
within 24 hours.
Clinic: Please fax completed COC/Chain of Custody &/Or BAT
results to WorkCare ASAP. Fax to: 714-922-1038. You may also e-mail results
to: drugscreenteam@workcare.com

If drug screen collections are requested: Please use the WorkCare Chain of Custody
If a rapid/instant drug screen is requested, please include the results with the exam
paperwork when faxing or emailing.

Questions:
Should you have ANY questions on the above requests, please do not hesitate to contact
WorkCare. (800) 455-6155 x2222

WorkCare thanks you for your attention

to the expedient nature of these exams!
This collection is being performed for Pre Employment
purposes. In order to clear the employee we need this
information ASAP.
Thank You
 Today's Date: 08/24/2017
WorkCare Appointment Protocol Page: 1
Encounter Number: S 1857451611
**If employee is known or suspects that he/she may have an adverse reaction to completing elements of the physical,
(such as blood draws, physical limitation, etc.) then the employee should notify WorkCare at the time they scheduled the
physical so that appropriate safeguards may be taken to protect the health of the employee.**

The following employee has been scheduled for the MEDICAL PROCEDURES listed below on the date
and at the location shown. If you are unable to keep this scheduled appointment or have any
questions, please contact me at the number listed below.
Sheila Nghe
EXAM INFORMATION
Employee Nguyen, Hung Company O'Brien & Gere-Syracuse, NY Appt Date 08/28/17
Site Appt Time 10:00am
CONTACT INFORMATION

Client Svc Rep Sheila Nghe Clinic INDUSTRIAL MEDICAL ASSOCIATES -CANAL
Phone 800-455-6155 Ext. 2423 Address 961 Canal Street
E-Mail sheila.nghe@workcare.com Syracuse, NY 13210
Fax 714-922-1013 Phone 315-478-1977 Fax 315-475-2909
EMPLOYEE INSTRUCTIONS
Please bring photo ID
NOTE: The following tests and procedures listed below will be performed. DO NOT leave until all of them have been completed.

There may be a corresponding fee for no show and cancelled appointments without 24 hour notice.

CLINIC INSTRUCTIONS
IMPORTANT: The College of American Pathologist (CAP), our laboratory accrediting agency, requires changes regarding proper
specimen labeling in order to improve patient safety. Below is an excerpt from the CAP Laboratory General
Checklist:
GEN.40491 ? All Primary specimen containers are labeled with at least 2 patient-specific identifiers.
The identifiers must correspond to information on the patient?s test request form. WorkCare does not rely on
request forms but our electronic order so DOB and Name are ESSENTIAL.
Please check and confirm all identification prior to examination. Mark Friday appointments for Saturday delivery.
Check expiration date on all blood tubes. If expired, DO NOT USE. Do not store tubes in hot location. No more
than 2 attempts to collect blood unless the employee agrees to 1 additional attempt.
AUTHORIZED SERVICE: Pre-Employment

laboratory components to be performed (COLLECTION ONLY)

X Drug Screen - Non-SAMHSA (Non-Federal) Please use the NON-FEDERAL chain of custody form.
* Please mark panel # 88675 on the chain of custody form.
* Please mark reason Pre-Employment on chain of custody form.

Note: Clinic: Please use a WorkCare Chain of Custody form for this drug screen collection - Please Mark Panel #88675 on the
Non Nida Chain Of Custody Form. If the panel number is not listed as an option on the COC please mark other and write
in the panel number. Please send specimen the same day of collection. Please fax Chain of Custody Form to WorkCare
at 714-922-1038. Thank you.

Any treatment outside of what is authorized on this protocol must be approved by WorkCare. Please contact the individual
responsible for scheduling the appointment at 800-455-6155 Ext. 2423
 Today's Date: 08/24/2017
WorkCare Appointment Protocol Page: 2
Encounter Number: S 1857451611
**If employee is known or suspects that he/she may have an adverse reaction to completing elements of the physical,
(such as blood draws, physical limitation, etc.) then the employee should notify WorkCare at the time they scheduled the
physical so that appropriate safeguards may be taken to protect the health of the employee.**

The following employee has been scheduled for the MEDICAL PROCEDURES listed below on the date
and at the location shown. If you are unable to keep this scheduled appointment or have any
questions, please contact me at the number listed below.
Sheila Nghe
EXAM INFORMATION
Employee Nguyen, Hung Company O'Brien & Gere-Syracuse, NY Appt Date 08/28/17
Site Appt Time 10:00am
Please do not bill O'Brien & Gere Limited or the patient. All billing should go directly to:
Send Kit and/or Paperwork to:
WorkCare MEDTOX
300 S. Harbor Blvd., Suite 600, Anaheim, CA 92805
Phone: (800) 455-6155 Fax: (714) 456-2154
Records Disclosure Statement - Custodial

Exam Type: Drug Screen

EMPLOYEE: Nguyen, Hung LOCATION: O'Brien & Gere-Syracuse, NY

EMPLOYER: O'Brien & Gere Limited POSITION:
DATE OF EXAM: August 28, 2017 SITE:
CLIENT SERVICES
REPRESENTATIVE: Sheila Nghe PHONE NUMBER: 800-455-6155 Ext. 2423

1. I understand that WorkCare, Inc., administers the drug testing program for O'Brien & Gere Limited . In
administering the program, I understand that WorkCare, Inc., will receive the results of my drug test.

2. I understand that WorkCare, Inc., is the Medical Review Officer for O'Brien & Gere Limited stated above.

3. I also understand that my employer will receive a status report.

4. I further acknowledge that I understand that INDUSTRIAL MEDICAL ASSOCIATES -CANAL is solely the
urine/hair/breath collection agent.

Date: 08/25/2017

Signature of Individual: