Mountain Medical Immediate Care
Occupational Health Services Contract
DRUG TESTING PANELS
❒4 Panel: $37.00 (DFWTG)
❒12 Panel: $50.00 (EDS50F)
Amphetamines
Cocaine
Opiates
Phencyclidine (PCP/Angel Dust)
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Ecstasy
Marijuana
Methadone
Methaqualone
Opiates
Phencyclidine (PCP)
Propoxyphene
❒DOT 5 Panel: $55.00
❒5 Panel: $40.00 (DFW50G)
Amphetamines
Cocaine
Marijuana
Opiates
Phencyclidine (PCP/Angel Dust)
❒9 Panel: $45.00 (SAP750F)
Alcohol
Amphetamines
Barbiturates
Benzodiazepines
Cocaine
Ecstasy
Marijuana
Opiates
Phencyclidine (PCP/Angel Dust)
❒Medical Review: $25.00
❒EtG Only: $50.00
*Ask about other panels we can offer
1. For what reasons would you like drug/alcohol testing provided?
_______________________________________________________________________
2. Are we to do a different drug panel for different reasons of testing (i.e. 5 panel for
pre-employment but 12 panel for post-accident)?
If so, please specify ________________________________________________
_______________________________________________________________________
3. Name and phone number of Company Contact(s):
_______________________________________________________________________
_______________________________________________________________________
4. What method of notification would you like for results?
□ Telephone, is it ok for us to leave a voice mail?
YES
NO
□ Email, email address: __________________________________
□ Fax, fax number: _____________________________________
□ US mail, mailing address: _______________________________
1302 NE Third Street · Bend, OR 97701 · 541-317-0909 Ext 225 · Fax: 541-317-0533 · M-F 8am-7pm, S-S 10am-3pm
· www.mtmedgr.com
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Breath Alcohol Tests
$35.00
Breath Alcohol Confirmation
$20.00
Audiometry
$57.00
Flu Vaccination
$20.00
Hepatitis B Vaccination (per vaccine)
$70.00
Includes injection cost
□ Hepatitis A Vaccine (per vaccine)
$120.00
Includes injection cost
□ PPD (TB Skin Test)
$26.00
□ Physical Exam
$95.00
□ DOT Physical
$95.00
□ Spirometry – Pulmonary Function Test
$90.00
□ Lab processing fee
$26.00
□ Venipuncture
$15.00
□ Hepatitis B antibody
$17.00
□ Hepatitis A antibody
$19.00
□ OSHA Respiratory Questionnaire
$25.00
□ Respiratory Fit test exams
$100.00
□ Manual Lift Test/Push and Pull
$50.00
□ Back Evaluation
$42.00
□ Chest X-ray
$129.00
□ EKG w/interpretation
$112.00
□ DOT or NON DOT drug test collection only
$20.00
□ Drug screen collection Offsite Setup
$40.00 plus FedEx fees
□ Afterhours Emergency service
$300 plus service fees
Our afterhours phone number is 541-280-0229
Company Name: ___________________________________________
Billing Address: ____________________________________________
City: _______________ State: __________ Zip: __________________
Phone: _____________________ Fax: _________________________
Contact Name: _____________________Phone: __________________
Payment is due upon receipt of invoice; all remittance must include a
statement number.
_____________________________
Company Representative Signature
Date: __________________
______________________________
MMG Representative Signature
Date: __________________
1302 NE Third Street · Bend, OR 97701 · 541-317-0909 Ext 225 · Fax: 541-317-0533 · M-F 8am-7pm, S-S 10am-3pm
· www.mtmedgr.com
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