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U.S. Geological Survey Manual

U.S. Geological Survey Manual

Appendix 24-3

USGS Example of Medical Services Request for LD




We are referring ______________________ for the following test(s) and/or examination under our Medical Surveillance Program:

Place of employment/field station ___________________________________.

Screening Test: Lyme Disease, most current testing protocol.

1. Establish baseline antibody level prior to exposure to tick infested areas.

2. Test if individual has developed symptoms of Lyme Disease.

3. Test at conclusion of the tick season.

NOTE: This authorization for testing is for medical surveillance purposes only. Reimbursement for medical treatment of employment related injuries or illnesses are subject to the provisions of the Federal Employees Compensation Act.

If this service is provided by an interagency agreement with the Public Health Service (PHS), please include the PHS agreement number.

Please provide a copy of the results to the employee named above.

We would also appreciate having a copy of the test results forwarded to our servicing Personnel Office for retention in the employee's medical file, envelope enclosed. The mailing address is: __________________________________.



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Last modification: 28-Aug-2002@17:03