OccuCare

Company Profile
This form is vital to insure procedures are followed correctly. Should one of your employees utilize the OccuCare Clinic to report an injury or illness and you are not aware, this form will provide a protocol to follow and contacts to call.
Company:		Date:
Address:
City:	State:		ZIP:
Phone:		Fax:
Type of Business		# Employees:
Contact Information
Contact		Title	Phone
Contact		Title	Phone
Post accident drug screen required: Yes No
Call results of drug screen to:			Phone
Call results of injury treatment to:			Phone
Billing Information
Billing Contact			Phone
Bill to:
Address:
City:	State:		ZIP:
Workers Compensation
Send claim to: Company Carrier W/C Alternative
W/C Carrier			Policy #:
Address:
City:	State:		ZIP:
Light duty available: Yes No
Comments: