| Employer
Information |
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Company:
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Division:
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No. of Employees:
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Mailing
Address:
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City,
State, Zip:
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Physical
Address:
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City, State,
Zip:
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Phone:
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Fax:
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E-mail:
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Nature
of Business:
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WorkLink
Client:
Yes
No
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| Business
Hours Contact |
Primary
(First & Last Name):
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Alternate
(First & Last Name):
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Title:
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Title:
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Phone:
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Phone:
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E-mail:
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E-mail:
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| After-Hours
Contact |
Primary
(First & Last Name):
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Alternate
(First & Last Name):
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Title:
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Title:
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Phone:
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Phone:
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E-mail:
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E-mail:
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| Preferred
Company Physician/Clinic Information |
| Preferred
Company Physician/Clinic:
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Phone:
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Fax:
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Address:
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City,
State, Zip:
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Medical
Director:
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Phone:
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| Is
modified duty available?:
Yes
No
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TWCC Subscriber?
Yes
No |
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| Testing
Requirements and Laboratory Preference |
Drug
Screen:
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Lab:
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DOT
Urine:
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Lab
phone:
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Non-DOT
Urine:
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Lab
account #:
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COC:
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Pick
up:
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Alcohol
Drivers:
Blood
Blood ORQ
EBT
EBT ORQ
ORQ
Urine
See Comments
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Alcohol
Others:
Blood
Blood ORQ
Breath Scan
Breath Scan ORQ
EBT
EBT ORQ
ORQ
Urine
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Does
the company require special forms?
Yes
No
If "Yes," indicate name of special form:
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Return-to-Work Status Information |
| Send
Return-to-Work Status by:
Mail
Fax
Phone |
Group
or Person:
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Address:
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City,
State, Zip:
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Phone:
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Fax:
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| Medical
Reports Information |
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| Send
Medical Reports (UDS/Alcohol) by:
Mail
Fax
Phone |
| Confidential?
Yes
No |
Group
or Person:
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Address:
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City,
State, Zip:
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Phone:
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Fax:
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| Occupational
Insurance Carrier Information |
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Occupational
Insurance Carrier:
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Policy
#:
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Address:
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City,
State, Zip:
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Contact:
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Phone:
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Fax:
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| Preferred Physicians |
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Authorized
Employer Contact:
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