Date:
Company Information Form
Company Name
No. of Employees
Company Address City
State Zip
Company Phone Company Fax
Contact Name Contact Email
Personnel Able to Authorize Visits Phone
Accounts Payable Contact
Name
Phone
Email
Fax
1.
2.
3.
4.
After-hours Contact Phone
1.
2.
Workers Compensation Insurance Carrier Information
Carrier Name Carrier Phone
Carrier Address City State Zip
Policy #
Effective Date (if available)
Carrier Fax
Special Instructions
Reason for Visit
On the Job Injury
Collection Only Lab Name:
Other:
Standard Drug Screens
Standard 10-Panel
Standard 5-Panel
DOT Drug Screen
Instant Drug Screens
Instant 10-Panel
Instant 5-Panel
Other Services
Breath Alcohol Test
DOT Physical
Basic Occupational Physical
Other (please explain):
Pre-Employment Services
Drug Screen with Injury?
Yes No
Results Reporting
Online
Mail
Name
Email
Fax
Fax
Email
Contact Name
Number
Please specify your preference for receiving physicals,
work, status reports, etc.
Please specify your preference for drug screen results only
Thank you for choosing CareNow as your occupational healthcare provider.
Please fax completed form to 844-226-1336, ATTN: OccMed Team or email to CareNowOccMed@HCAHealthcare.com
