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*:---Company / EmployerThird Party AdministratorWorker Comp CarrierEach service will be billed to a different payer 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?*:---YesNo 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:---I will send a stack of chain of custodies to your location to keep on file.I will send a copy of the chain of custody with every employee who comes in for a drug screen [/group] Does employer use a Third-Party Administrator (TPA) to manage occupational health services?*:---YesNo [group use-tpa-yes] TPA Information TPA Name: TPA Address: TPA Contact Name: TPA Phone: TPA Fax: TPA Email: [/group] Services Requested*:---Workers CompensationOccupational Medicine [group occupational-medicine] Occupational Medicine Please list any services you may utilize at our clinic Drug Screens DOT drug screen5 panel drug screen10 panel drug screen7 panel drug screen + alcoholSynthetic marijuana/bath salts14 panel send out drug screen14 panel rapid drug screenConfirmation of rapid non-negative drug screenCollection only drug screenDirect Observation of Urine Collection 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) Other Testing Pulmonary function test (PFT)Respirator fit test questionnaireQualitative respirator fit testAudiogram- AutotestAudiogram- Threshold testLift testSnellan vision testIshahara color vision testX-ray Lumbar 2 viewX-ray chest 2 viewX-ray chest- B readTD- tetanusUrine cobalt testUrine nickel testBlood draw - leadBlood draw - zincBlood draw - ironBlood draw - magnesiumHep B titerHep B vaccineTb skin test2 step TB skin testFlu shot Blood Bourne Pathogen Post Exposure Protocol HIV - BaselineHepB HBsAg - BaselineHepB HBsAb - BaselineHepC HCAb - BaselineALT - BaselineHIV - 6 WeeksHCV RNA - 6 WeeksHIV - 3 MonthsHIV - 6 MonthsHepB HBsAg - 6 MonthsALT [/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 Drug Screens DOT drug screen5 panel drug screen10 panel drug screen7 panel drug screen + alcoholSynthetic marijuana/bath salts14 panel send out drug screen14 panel rapid drug screenConfirmation of rapid non-negative drug screenCollection only drug screenDirect Observation of Urine Collection Breath Alcohol Tests DOT breath alcohol test (BAT)NON-DOT breath alcohol test (BAT) [/group]
