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On-Site Service Request

Medical Authorization

Custom Client Form

Step 1 of 4

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COMPANY INFORMATION

Company Name(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

BILLING INFORMATION

Accounts Payable Contact Person(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

Accounts Payable Email Address(Required)

Tax ID:(Required)

Accounts Payable Phone(Required)

Accounts Payable Fax(Required)

WORKER'S COMPENSATION INFORMATION

Does Worker's Compensation Apply?(Required)

Yes

Invoice options for Worker's Compensation Claims

Invoice directly to Worker's Comp Carrier (details provided below)

Invoice directly to Employer AP Contact (by traditional invoice)

Invoice directly to AP Contact (by Insurance Claim form; employer is responsible for filing claims to carrier and payment.)

Worker's Comp. Insurance Company(Required)

Worker's Compensation Insurance Address(Required)

Street Address Address Line 2 City State ZIP Code

Worker's Compensation Insurance Phone(Required)

Worker's Compensation Insurance Fax(Required)

THIRD PARTY ADMINISTRATOR (TPA)

Company Name(Required)

Billing Address(Required)

Street Address Address Line 2 City State ZIP Code

HUMAN RESOURCES / HR MANAGEMENT

HR Main Contact(Required)

Phone(Required)

Secondary Contact

Phone

Email(Required)

Address

Street Address Address Line 2 City State ZIP Code

SAFETY AND INJURY MANAGEMENT

Injury Management Contact

Phone

Safety Manager

Phone

Safety Manager #2

Phone

Panel of Tests Requested

Post-Incident Drug Screen

DOT

Non-DOT

Rapid

Breath Alcohol

DOT

Non-DOT

ACCOUNT PROFILE Please provide the contact information for the manager for servcies related questions.

Name

We will keep you up to date with HealthWorks Medical's monthly news and OSHA updates. Please list your appropriate staff and email addresses below.

Name

Phone

Which services does your company have protocols? (Check all that apply.)

Drug Screen

Physical Exam

Fit-for-Duty Exam

Injury Treatment

Case Management

Hearing Conservation

Respirator Fit

Wellness Program

On-Site Services

Other

Please Indiciate HealthWork Medical's services that your comapny intends to use. (Please check all that apply.)

Drug Screen

Physical Exam

Fit-for-Duty Exam

Injury Treatment

Case Management

Hearing Conservation

Respirator Fit

Wellness/Health Risk/Vaccination

On-Site Services

In-House Medical Staffing

Telemedicine/EME

Worker's Comp

Direct Primary Care

Marine Medical Management Solutions

What is the approximate number of people that your company employs locally? Choose one.

1-10

11-50

51-100

101-250

251-500

501-1000

1001-1500

1501-2500

2501-5000

5000+

What is the approximate number of people that your company employs nationwide? Choose one.

1-10

11-50

51-100

101-250

251-500

501-1000

1001-1500

1501-2500

2501-5000

5000+

Please indiciate the HealthWorks Medical clinic locations that yo uplan to utilize. Select all that apply.

Paducah, Kentucky

Mayfield, Kentucky

On-Site

What is the nature of your business?

Contractor

Plant/Refinery

Service

Transportation

Commercial/Retail

Government

Other

How did you hear about us? Choose one.

Website

DISA Referral

Contractor Referral

Marketing Representative

Networking Event

If a Marketing/Sales Representative contacted you initially, please type the person's name below.

DESIGNATED EMPLOYER REPRESENTATIVE Your company's DER will be responsible for managing your employee screening results and will have access to these results on HealthWorks Medical's online portal.

Name

First Last

Phone

ANTI-SPAM QUESTION: How many eggs are typically in a carton?(Required)

Company(Required)

Location of On Site Work

Requested Date of Service(Required)

Month

Day

Year

Requested Time(Required)

Hours

Minutes

AM/PM

Requested by:(Required)

Email(Required)

Phone(Required)

Tests Needed(Required)

Drug Screens

Breath Alcohol

Physicals

Audio

Pulmonary

Fit Tests

Flu Shots

X-Ray Services

Biometrics

Labs

Other

Drug Screen Type

Drug Test Quantity

Breath Alcohol Type

Breath Alcohol Test Quantity

Physical Type

Physical Test Quantity

Audio Type

Audio Test Quantity

Pulmonary Type

Pulmonary Test Quantity

Respirator Fit Test

Quantitative (PortaCount)

Qualitative (Odor Test)

Mask #1

Mask #1 Type

Half-Face

Full-Face

Mask #2

Mask #2 Type

Half-Face

Full-Face

Mask #3

Mask #3 Type

Half-Face

Full-Face

Flu Shot Type

Flu Shot Quantity

Other Test Type Request

Other Test Type Quantity

Accommodations Needed

Tests will be performed using our facilities.

HealthWorks will provide mobile medical unit(s).

How would you like to receive your results?

Individual

Collated Binder

If you do not receive a confirmation by phone within one business day, please call HealthWorks to confirm your request was received: (270) 448-9355.

ANTI-SPAM QUESTION: How many eggs are typically in a carton?(Required)

Medical Authorization Requests are managed through our Patient Portal.

Access Patient Portal

Please contact us for further information regarding Custom Client Forms: 270-448-9355.

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How Can We Help?

We look forward to supporting your organization and affordably address the healthcare needs of your employees and their families.

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