If yes, please provide detailed information regarding verbalizations or threats made:
If yes, please list the name of your occupational medicine site:
After completion of the entire form, please see below for next steps.
Member/Employee: Please call TEAM Corporation at (651) 642-0182 to set up your appointment(s).
Supervisor: This form must be received in our office prior to scheduling the member/employee’s appointment. For confirmation of contact or attendance at TEAM Corporation, an Authorization for Release of Protected Health Information can be signed and completed by member/employee and submitted along with this form. Please complete this form with the member/employee, give a copy to the member/employee, then fax/email a copy to TEAM Corporation at (651) 642-1809 or email@example.com.