Resources for Employers
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Authorization for Examination Form – The "Pink Slip"
A tool MeritCare offers to help make your experience at our clinics as smooth as possible is the Authorization for Examination or Treatment Form. Also known as "pink slips," these forms help our staff clearly understand what services employers are requesting. Many times, employees are not sure what services they are coming in for. If they have a pink slip with them, these questions are answered and our staff don't need to locate a supervisor to clarify what's needed – saving both you and our staff time and frustration. In addition to clarifying services, these slips also help eliminate errors in registration and billing.
Pink slips also provide a special instructions section. This section can be used to describe additional services needed that are not specifically listed. For example you can request anything from injury care to audiograms, respiratory protection to vaccines, and any other services available at our clinics.
If you have questions about how to use this form or would like to receive a supply of these forms, please contact your MeritCare employer relations representative.
- Tim Hestdalen, Fargo/Moorhead area clients – (701) 234-6739
- Lori Bradseth, Bemidji area clients – (218) 333-4735
- Chuck Ulrich, other regional clients – (701) 234-6985; toll free (800) 437-4010, ext. 6985
Below are links to the examination forms you can print and use right away.
Examination and Treatment Form – Fargo Occ Health Clinic 
Examination and Treatment Form – Regional Clinics