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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: