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Revised 1/27/2021 BLOOD SCREENING VERIFICATION FORM The City of Missoula is committed to improving the health and productivity of our workers and retirees. Health screenings are an invaluable tool for early detection and encourage healthy behaviors. As the healthcare provider please complete the information below. Please bill services under preventative care or wellness unless tests are conducted as part of ongoing treatment. City of Missoula, Human Resources Department 435 Ryman Street Missoula, MT 59802 Phone: [PHONE REDACTED] Fax: [PHONE REDACTED] Employee Name: DOB: Department: Patient Name: Self Spouse * Mandatory for males 50 years of age and older Patient Signature: Date: Physician Signature: Date: Health Maintenance & enter date completed) Date: Lab CBC Metabolic Panel Lipid Profile PSA (Male Only) * SIGN SIGN