Service Request Form

1
Service Request Form for U.S. HealthWorks
Conditional Job Offer Date _____________________
_________________ Start Date
__________________________________________________
__ (Start date should be five (5) working days
after offer date) Employees Anticipated Time of
Arrival for Test ______________AM PM Facility
Location Selected (See Below)
___________________________
3 Day Deadline is __________.
HCC Hiring Manager or Designee 1. Do not
leave any lines on this form blank. All required
fields must be completed. 2. Make sure to
indicate the 72 hour (3 day) deadline and inform
the employee. 3. Fax the completed request form
to the appropriate US HealthWorks location
immediately after conditional job offer is
made! 4. Attach request form, along with fax
confirmation transmittal to employees paperwork.
Patient Name __________________________
Patient Contact No. _____________________ Employ
er Houston Community College System Return
Fax [phone] Authorized by (Please
Print) ___________________________________________
____________ (Hiring Manager, Dept. Chair or
Designee) Authorizers Title
__________________________________________________
____________ Authorizers Signature
__________________________________________________
________
Remind Employee PICTURE ID WILL BE REQUIRED
Type of Service X NON-DOT Drug Test (10 Panel
Test Required) X Pre-Placement
Houston Area Test Facility Locations
Brazosport Greenspoint
Northwest
1102 N. Brazosport Blvd. Freeport, TX 77541 Tel
979-233-6571 Fax [phone] Hours Monday-F
riday 8AM 5PM
16630 Imperial Valley Dr. Suite 115 Houston, TX
77060 Tel [phone] Fax
281-260-0676 Hours Monday-Friday 8AM 5PM
17420 Northwest Freeway Houston, TX 77040 Tel
713-466-0044 Fax [phone] Hours Monday-Fri
day 8AM 5PM
Southwest
HCOM
Hempstead
1414 S. Loop W., Suite 200 Houston, TX
77054 Tel [phone] Fax
713-790-0507 Hours Monday-Friday 8AM 5PM
1500 West Loop N, Suite 137 Houston, TX
77008 Tel [phone] Fax
713-880-3330 Hours Monday-Friday 8AM 5PM
10521 Corporate Drive Stafford, TX 77477 Tel
281-277-7997 Fax [phone] Hours Monday-Fri
day 8AM 5PM
Form HCC-HR-520A