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					                                                    TREATMENT AUTHORIZATION CARD

                                                                      Please bring photo I.D.

When seeking medical care for a work related injury/accident:
     Present this card
     Tell the staff this is a work-related injury/accident
     Tell the staff your employer’s name and address

Be sure to request:
     A follow-up call to your employer
     A written return-to-work authorization form
     A follow-up appointment or referral to Affinity Occupational Health

Please complete this following and send this card with your employee:
Company: Kimberly Area School District                                              Phone: 920-788-7900
Company Contact: Connie School                                                      Confidential Fax: 920-788-7919
Employee:
Appointment Date:                                                                   Time:

Services Requested:
    Physical                                               Injury/Illness                           Follow-up care
    DOT Drug screen                                        Non-DOT Drug Screen                      Breath Alcohol Test
    Audiogram                                              TB                                       Other
Notes:

After Hours Drug Testing (before 7:30am and after 5:00pm, M-F)
For after hours drug/alcohol testing, please go directly to the lab.
St. Elizabeth Hospital Lab: (920) 738-2121  Mercy Medical Center Lab (920) 223-1200 (ask for the lab)
Send/call results of the after hours screening to (employer representative):
Phone:                              Confidential Fax:




                          Menasha                                                           Oshkosh
   Located at the corner of Appleton Rd. and Airport Rd.               Located on Koeller St. in Oshkosh across from Target.
   Across from Kitz & Pfeil True Value Hardware
Affinity Occupational Health Clinics:

                  Please call ahead to schedule an appointment.
        Appointments are available Monday through Friday, 7:30am – 4:30pm
 Affinity Occupational Health - Menasha
 1186 Appleton Road.  Menasha, WI 54952  920-727-8700
 Hours: Monday – Friday 7:30am – 5:00pm

 Affinity Occupational Health - Oshkosh
 1855 S. Koeller St.  Oshkosh, WI 54902  920-223-7075
 Hours: Monday – Friday 7:30am – 5:00pm


Driving Directions:

Affinity Occupational Health - Menasha
From the north: Take Hwy 41 south to Hwy 441 south, exit Appleton Rd., turn left. Our office is on
the right just past Airport Road.

From the south: Take Hwy 41 north to Hwy 10/441, exit Midway Rd., turn right. Turn right on
Appleton Rd. Our office is on the right, just past Airport Rd.

Affinity Occupational Health - Oshkosh
From the north: Take Hwy. 41 south, exit 9th Ave., turn left. Turn right on S. Koeller St.
(travel .9 miles); our office is on the right.

From the south: Take Hwy. 41 north, exit South Park Ave./Ripon Rd.(Hwy. 44), turn right.
Turn left on S. Koeller St. (travel 0.5 miles); our office is on the left.




     For After-Hours Information, Call Affinity NurseDirect, a 24-Hour information call-in service:
               920-738-2230 Fox Cities  920-231-6578 Oshkosh  1-800-362-9900 Toll Free




           Affinity Occupational Health is dedicated to continually improving the health and well-being of employees
                             through partnering with the corporate community and its labor force.
                                                 Drug Screen
                          Drug screen only per Connie School at Kimberly Area School District


A drug screen is required prior to placement with the Kimberly Area School District. Kimberly Area Schools
has a contract with Affinity Occupational Health and will pay the full cost of your drug screen. Affinity
Occupation Health allows walk-in’s but they do prefer that you make an appointment. The phone number for
the Menasha location is 920-727-8700 and the phone number for the Oshkosh location is 920-223-7075.


On the day of your drug screen appointment, please bring:

          Photo ID

Affinity Occupational Health will send the results directly to us.

Affinity Occupational Health - Menasha
From the north: Take Hwy 41 south to Hwy 441 south, exit Appleton Rd., turn left. Our office is on the right
just past Airport Road.

From the south: Take Hwy 41 north to Hwy 10/441, exit Midway Rd., turn right. Turn right on Appleton Rd.
Our office is on the right, just past Airport Rd.

Affinity Occupational Health - Oshkosh
From the north: Take Hwy. 41 south, exit 9th Ave., turn left. Turn right on S. Koeller St. (travel .9 miles); our
office is on the right.

From the south: Take Hwy. 41 north, exit South Park Ave./Ripon Rd.(Hwy. 44), turn right. Turn left on S.
Koeller St. (travel 0.5 miles); our office is on the left.




These directions are to the Theda Care Appleton and Oshkosh locations. More Theda Care at Work
Locations can be found on the next page.

				
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posted:1/2/2012
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