New Client Sign Up Form by umxE48c

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									Date: _______________________                      New          Revised


Company Name: ________________________________________________________________
Address: ______________________________________________________________________
City: ______________________________ State: _______________ Zip Code: _________
Telephone: ____________________________ Secure Fax#: ____________________________
# of Employees: _______________________
Type of Business: _______________________________________________________________
Referred by: ____________________________________________________________________



Contact 1: ________________________________       Title: __________________________
Direct #: ____________________________      Mobile/Pager: __________________________
E-maill: ________________________________


Contact 2: ________________________________       Title: __________________________
Direct #: ____________________________      Mobile/Pager: __________________________
E-mail: _______________________________


Contact 3: ________________________________       Title: __________________________
Direct #: ____________________________      Mobile/Pager: __________________________
E-mail: _______________________________


Work Comp Carrier: ____________________________________________________________
Address: ______________________________________________________________________
City: ______________________________ State: ___________ Zip Code: ______________
Telephone: _______________________________        Fax: ____________________________
Policy #: ________________________________        Effective Date: __________________
Do you have modified duty available?
 Available  On case by case basis         NOT Available

Who do we bill for First Aid?
 Company              Work Comp Carrier

Do we drug screen your injuries?
 All injuries
 Upon company request ONLY
 None
                         DRUG SCREENING PROGRAM
NOTE: Unless otherwise specified all Non-DOT drug screen will be non-witnessed.
PREFERRED LAB:             _______________________________________
NOTE: Unless Laboratory is specified, CVO will use Quest as its preferred lab.

Cause/Suspicion:
   Non-DOT
   DOT
   Quickscreen/Rapid
   BAT
       Upon company request ONLY

Preplacement:
    Non-DOT
    DOT
    Quickscreen/Rapid
    BAT
       Upon company request ONLY
Post Injury:
    Non-DOT
    DOT
    Quickscreen/Rapid
    BAT
        Upon company request ONLY
Random:
    Non-DOT
    DOT
    Quickscreen/Rapid
    BAT
    Upon company request ONLY

Results:  Fax to company and mail hard copy
          Call with results and mail hard copy
                            PHYSICALS PROGRAM
Preplacement Physical:
   Functional Capacity Exam (please attach job descriptions)
   TB Skin Test
   Audiogram
   Spirometry
   Other: _______________________________________________________________


Results:  Fax to company and mail hard copy
          Call & Mail hard copy
DMV Initial:
Drug Screen:  DOT
Results:      Hand carry P.E.R., DMV form and card to company
              Mail P.E.R and DMV form to company & have driver keep DMV card

DMV Recert:
Results:        Hand carry P.E.R., DMV form and card to company
                Mail P.E.R and DMV form to company & have driver keep DMV card

FFD/RTW Physical:
Drug Screen:  Non-DOT             Quickscreen        DOT
 Functional Capacity Exam (FCE)
Results:      Fax P.E.R. to company and mail hard copy
              Call in FFD results and mail hard copy

                    MEDICAL SURVEILLANCE PROGRAM
 TB Skin Test              Audiogram          Spirometry
 Hep A Series             Hep B Series        Mask Fit Test


Results:  Fax to company and mail hard copy
          Call & Mail hard copy

								
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