Name: Patient Plus
Price range: $

Company Name

Company Physical Address

Billing Information

Accounts Payable Contact Person

Billing Address

Email Invoices? YesNo

Invoice Email Address

Phone

Fax

Tax ID

Workers Comp. Information

(N/A) If Not Applicable Select N/A

Worker's Comp Insurance Company

Insurance Address

Insurance Phone

Insurance Fax

Third Party Administrator (TPA)

Company Name

Billing Address

Human Resources Risk Management

HR Main Contact

Phone

HR Secondary Contact

Phone

HR Email

Safety and Injury Management

Injury Management Contact

Phone

Safety Manager(s)

Phone

Post-Incident Drug Screen DOTNon-DOTQuick

Panel of Test

Breath Alcohol DOTNon-DOT

Account Profile

Name of responsible manager for service related questions?

Office Phone

Cell Phone

Other - Please Describe

Designated Employer Representative (DER)

our company's DER will be responsible for managing your employee screening results and will have access to these results on the online portal.

Name

Phone

How Did You Hear About Us?

Please Specify

Occupational Medicine Sign Up

Account Setup Form

Billing Information

Workers Comp. Information

Third Party Administrator (TPA)

Human Resources Risk Management

Safety and Injury Management

Account Profile

Designated Employer Representative (DER)

Services

Employers

Contact Us

Blog

Locations