OCCUPATIONAL MEDICINE COMPANY PROFILEPage 2 of 2 REVISE DATE: 07/19/2016 OCCUPATIONAL MEDICINE...
Transcript of OCCUPATIONAL MEDICINE COMPANY PROFILEPage 2 of 2 REVISE DATE: 07/19/2016 OCCUPATIONAL MEDICINE...
Page 1 of 2 REVISE DATE: 07/19/2016
OCCUPATIONAL MEDICINE COMPANY PROFILE P: 808.456.CARE (2273) |E: [email protected] W: www.ucarehi.com
Company Name:__________________________________________________ Contact Name:___________________________________________
Company Address:_____________________________________________________________________________________________________________ Street Address City/State/Zip
Phone Number:___________________________________________ Fax Number:______________________________________________________
Authorization List:_____________________________________________________________________________________________________________
BILLING INFORMATION
Do you want your statement printed? Yes No
How would you like your statement printed? Summary (All employees on a single page)
Detailed (Each employee on a single page)
Both
Would you like to include SSN on statement? Yes No
WORKERS COMPENSATION/WORK-RELATED INJURY INFORMATION
Is your company self-insured? Yes No
*If no, please fill out the following information
Name of WC Insurance Company:______________________________________________________________________________________________
Address:_________________________________________________________________________________________________________________________ Street Address City/State/Zip
Contact Name(s):_______________________________________________________________________________________________________________
Contact Number:_________________________________________________ Fax Number:________________________________________________
EMPLOYEE PAID SERVICES (EPS) INFORMATION
How would you like to pay for the services? Employee Employer Company HR Company Headquarters * If address is same as company address above, you may leave the mailing section blank.
Mailing Address:________________________________________________________________________________________________________________
Street Address City/State/Zip
Contact Name:_____________________________________________ Contact Number:__________________________________________________
Payments will be made attention to:___________________________________________________________________________________________
*HOW WOULD YOU LIKE US TO SEND THE RESULTS (CHECK ALL THAT APPLY)?
Fax
Employer Portal
*By selecting the Employer Portal you will be provided with a username and password to the indicated email address below and a how-to hand out.
Mailing Address:________________________________________________________________________________________________________________ Street Address City/State/Zip
Email:______________________________________________________________ Email password:___________________________________________ *To access results, please provide us with a customized six character password.
Fax Number:_______________________________________________________ Attention to:_______________________________________________
LOCATION OF INTEREST: KAPOLEI KAILUA PEARL CITY WAIKIKI Please select all that apply
Page 2 of 2 REVISE DATE: 07/19/2016
OCCUPATIONAL MEDICINE COMPANY PROFILE P: 808.456.CARE (2273) |E: [email protected] W: www.ucarehi.com
EMPLOYER PAID SERVICES (EPS) SERVICES REQUESTED
Physicals: Yes No Please select all that apply: Non-DOT DOT/CDL/PUC Medical Card Basic
Reason for Physical: Pre-Employment Return-to-Work/Fit-for-Duty
Drug Screening: Yes No Please select all that apply: Non-DOT Panel 5 DOT Panel 5
Non-DOT Panel 10 Instant Panel 5
DOT Drug Collection *Only *Chain of Custody Form must be LabCorp
Drug Testing Medical Review Officer (MRO) Services: Use Company MRO Provide own MRO *Chain of Custody Form must be LabCorp
Name of MRO:_________________________________________________________________________________________________________
Address of MRO:_______________________________________________________________________________________________________ Street Address City/State/Zip
Phone Number:___________________________________________ Fax Number:_______________________________________________
Immunizations: Yes No Please select all that apply: Tetanus Flu TB/PPD MMR
Hepatitis B Series (Series of 3 shots)
Hepatitis A (Series of 2 shots)
Laboratory: Yes No Please select all that apply: Urinalysis CBC Zinc Protoporhin
(Collection only – please note prices are subject to change based on DLS) Lead Heavy Metal
Procedures: Yes No EKG
Respirator: Yes No Please select all that apply: Respirator Clearance (*Will proceed to Respirator Physical Exam if employee fails Respirator Questionnaire) Respirator Physical Exam
Qualitative Respirator Fit Test (*employee to provide resp. mask)
Alcohol Testing: Yes No Please select all that apply: DOT
Other Special Instructions:
__________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________
LOCATIONS PEARL CITY
1245 Kuala Street, St 103 Pearl City, HI 96782
P: 808.784.2273 F: 808.456.2274
KAPOLEI 890 Kamokila Blvd., Suite 106
Kapolei, HI 96707 P: 808.521.2273 F: 808.521.2274
KAILUA 660 Kailua Road Kailua, HI 96734 P: 808.263.2273 F: 808.263.2274
WAIKIKI 1860 Ala Moana Blvd., #101
Honolulu, HI 96815 P: 808.921.2273 F: 808.921.2274