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California CareDrivers: The Medical and TB Exam Authorization Form

Taylor F
Updated

In preparation for your Carbon Health appointment, print this packet, which contains your Authorization form, TB risk assessment form, and Medical exam form. Learn more about making an appointment here. 

You must complete the Authorization form before your appointment. Follow the steps below to complete the form.

  1. At the top of the form, print your name, date of birth, and the date.


  2. Complete the Services Requested section.

    • If you only need a TB risk assessment*, check the TB Risk Assessment box.

      *TB Risk Assessment should be completed first. As determined by the medical provider, it may be recommended that you complete additional testing. HopSkipDrive will cover the cost of a TB skin test, while the expenses for a blood test or chest x-ray will be your responsibility. You do not need to check any additional boxes.


    • If you only need a Medical exam, check the DOT Physical box:


    • If you need both the TB Risk Assessment* and the Medical exam, check both the TB Risk Assessment and the DOTPhysical boxes:

      *TB Risk Assessment should be completed first. As determined by the medical provider, it may be recommended that you complete additional testing. HopSkipDrive will cover the cost of a TB skin test, while the expenses for a blood test or chest x-ray will be your responsibility.


      Leave the Drug & Alcohol Testing section blank. Do not check any boxes in that section.
   You must fill out the authorization form before your appointment. If your name, DOB, Date, and services are not checked you may be turned away and asked to return at a later date. Please follow the instructions outlined above to prevent rescheduling.


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