Employer Profile

Employer Information

Name of Business*:

Address of Business*:

City*:

State*:

Zip Code*:

Contact Name*:

Phone Number*:

Fax Number:

Email*:

Who will be paying for each service*:

If each service will be billed to a different payer, please give details here:

Contact for Results*:

Contact for Results Phone*:

Contact for Results Fax:

Contact for Results Email*:

Do you have your own lab account?*:

Note: If you selected YES here, please be sure to mark “Collection Only Drug Screen” in the drug screen services section instead of choosing any other panel. This will ensure we utilize your lab account.

[group lab-account-yes]

Lab Information

Lab Name:

Chain of Custody will be:

[/group]

Does employer use a Third-Party Administrator (TPA) to manage occupational health services?*:

[group use-tpa-yes]

TPA Information

TPA Name:

TPA Address:

TPA Contact Name:

TPA Phone:

TPA Fax:

TPA Email:

[/group]

Services Requested*:

[group occupational-medicine]

Occupational Medicine

Please list any services you may utilize at our clinic

Physicals
DOT physicalWork physical- MainStreet formWork physical- employer formFit for duty physical

Breath Alcohol Tests
DOT breath alcohol test (BAT)NON-DOT breath alcohol test (BAT)

[/group]
[group workers-comp]

Workers Compensation

Workers Compensation Carrier:

Carrier Address:

Carrier City:

Carrier State:

Carrier Zip Code:

Carrier Contact Name:

Carrier Phone:

Carrier Fax:

Carrier Email:

Please list any services you may utilize at our clinic

Evaluation
Provider Evaluation of Work Comp Injury/work-related injury

Breath Alcohol Tests
DOT breath alcohol test (BAT)NON-DOT breath alcohol test (BAT)

[/group]

Employer Profile

Employer Information

Lab Information

TPA Information

Occupational Medicine

Please list any services you may utilize at our clinic

Workers Compensation

Please list any services you may utilize at our clinic

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