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Company Name

Primary Contact Name

First Name

Last Name

Phone

(###)

###

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What services are you interested in?

Injury Care

Drug Screening

Pre-employment Exams

Physical Therapy

Respirator Questionnaire/Fit Testing

Workplace Immunizations

Safety/Industrial Hygiene Consulting

OSHA 10/30-hour Training

Drug Screening

Describe any criteria you have for drug screening (e.g. all injuries, only motor vehicle or equipment incidents, only for property damage, etc.).

Restricted Duty Work

Please describe any light duty or restricted duty work you have available in as much detail as possible. This helps us assist in reducing time-loss.

Workers Compensation Insurance or Third-party Adjuster

Policy #

Insurance Adjuster

If you have an assigned or primary adjuster for workers compensation claims, put their name here.

Adjuster Email

Adjuster Phone

(###)

###

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Adjuster Fax

(###)

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Billing Information

Billing contact name, email and phone for services billed directly to employer

Employer Portal Access

Please provide a list of individuals you would like to have access to the portal. Include their email address and designated role (Billing, Scheduling, or Claim Management). Access can be updated at any time — you are able to add or remove users as needed.