TRAFFIC Detours and Parking Updates around Phoebe Putney Memorial Hospital

Make an Appointment

New Company Worksheet

Thank you for taking the time to fill out this form. Please complete all applicable sections and select desired services.

 
Company Name:  *Date: Your type of industry: Approx. number of employees: Address: City, State, Zip: Contact Name: (authorized to see results) Phone Number: Fax: E-mail: 
Billing Information: (if different from above)

 Billing Address: City, State, Zip: 
Billing Representative Information

 Billing Representative: (if different from above) Billing Rep Title: Phone Number: Fax: E-mail: 
Insurance Carrier Information

 Worker's Compensation Insurance Carrier: Billing Address of Insurance Carrier: City, State, Zip: 
Insurance Representative Information

 Insurance Representative: (if different from above) Select Insurance Documentation Requirement: 
Phone Number: Secure Fax: E-mail: 
Injury Treatment / Worker's Comp - let us know who is on your panel for referrals

 Select Desired Services: 
* Please inform your Worker's Comp Carrier, and let us know if you need additional information. 
Drug Screens - let us know where to send results

 Select Desired Services: 
Do you have your own lab or Chain of Custody (CCF) form? 
Do you need a DOT Consortium/Third Party Administrator? 

Physical Exams - appointments only, let us know where to send results

 Select Desired Services: 

Vaccinations / Titers - walk-ins only

 Select Desired Services: 

Other Services - some services are included in physical exams

 Select Desired Services: 

On-Site Services - we come to your location, call to schedule

 Select Desired Services: 
Other: 
 

How can we help you?