New Company Worksheet

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

MM slash DD slash YYYY

Billing Information: (if different from above)

Billing Representative Information

Insurance Carrier Information

Insurance Representative Information

Select Insurance Documentation Requirement:

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: