Authorization #

Authorization Form
TM
PTC eTest

Donor Information Employer Information

Name: Patrick Burr BWS SERVICES LLC

ID: XXXXXXX7446 PO BOX 1515
MEXIA, TX 76667
Phone: 580-579-8531
Fax: 254-562-6580
DER Name: WILL TAYLOR

Test(s) to be Performed

Pre-Employment DOT Drug Split Urine PTC.PTC.10116

Additional Information Site Information

A-DEPENDABLE DRUG TESTING

1304 N. LOOP 250 WEST STE. B
MIDLAND, TX 79703
Phone: 432-704-5181
Fax: 432-704-5183
Hours: M-F 8-5

Call ahead to confirm hours of operation

or if an appointment is needed!
Bring a valid photo ID and this authorization form.

Billing Information (For UA Collections & BAT only) Medical Review Officer

American Medical Review Officers, LLC

5 Compound Drive
Hutchinson, KS 67502
Phone: 866-294-8758
Pipeline Testing Consortium, Inc. Fax: 620-664-5594
Email: process@americanmro.com
7 Compound Drive
Hutchinson, KS 67502
Phone: 800-294-8758
Email: accounting@pipelinetesting.com
Note: PTC does not pay for physicals.

** ATTENTION **
Call the site to confirm their hours of operation and if an appointment is required

Present this authorization form and a valid photo identification

© Pipeline Testing Consortium, Inc. 2024