Sparrow Occupational Health Services New Client Information Form
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5OCCUPATIONAL HEALTH SERVICES
NEW CLIENT INFORMATION FORM
Please complete and fax to (517) 364-3914 or email to
ACCOUNT INFORMATION
COMPANY NAME:
CONTACT PERSON:
Phone:
Email:
ALTERNATE
Phone:
Email:
CONTACT PERSON:
SECURE FAX:
PREFERRED METHOD OF RECEVING REPORTS:
Email
Fax
Telephone
MAILING ADDRESS:
BILLING INFORMATION
COMPANY BILLING ADDRESS (IF DIFFERENT THAN MAILING ADDRESS):
WORKERS COMPENSATION INSURANCE INFORMATION
WC INSURANCE CARRIER:
WC INSURANCE BILLING ADDRESS:
CONTACT PERSON & PHONE:
Would you like your WC Invoices billed to:
Your company or
Directly to your carrier
DRUG SCREENING INFORMATION
DOES A THIRD PARTY ADMINISTRATE YOUR COMPANY’S
IF YES, NAME OF ADMINISTRATING COMPANY:
DRUG SCREENING PROGRAM?
YES
NO
DO YOU PERFORM DRUG TESTING AND/OR BREATH ALCOHOL TESTING WITH INITIAL INJURY VISITS?
BAT
DRUG TESTING
No Drug Test/BAT with injury Care
DRUG TESTING TYPE NEEDED (Check all that apply)
DOT Panel (revised Oct. 1, 2010)
Non-DOT:
4 panel
5 panel
6 panel
10 panel
MCOLES
Non-DOT Instant Urine (Point of Care Testing):
Other Panel:______________
4 panel
5 panel
12 panel
MRO SERVICES:
Collection Services Only:
Medical Review (MRO) on all specimens
Urine
Hair
Oral Fluid
Medical Review on Positive Only
SERVICES NEEDED (Check all that apply)
PRE-PLACEMENT PHYSICAL TO
ANNUAL/SURVEILLANCE PHYSICAL
INJURY CARE
INCLUDE:
TO INCLUDE:
BREATH ALCOHOL TESTING
Physical Exam
Physical Exam
DOT and/or NON-DOT
Urinalysis
Urinalysis
Beltone Audiogram
Beltone Audiogram
TB TESTING
Titmus Vision Screen
Titmus Vision Screen
Drug Testing (indicate type)
Laboratory Panels:
ANNUAL / SURVEILLANCE
Alcohol Testing
CBC
PHYSICALS
Laboratory Panels:
Comprehensive Panel
PRE-PLACEMENT PHYSICALS
CBC
Heavy Metal Screen
Comprehensive Panel
Blood Lead & ZPP
Heavy Metal Screen
Respirator Clearance
FITNESS FOR DUTY EXAMS
Blood Lead & ZPP
Respirator Fit Testing
Respirator Clearance
EKG
Pulmonary Function Testing
Pulmonary Function Testing
DOT PHYSICALS
TB Assessment
Chest Xray;
1 view
2 view
Vaccinations/Titers
Other:______________________________
RESPIRATOR FIT TESTING
Lifting Assessment- Indicate Lifting
Capacity Needed in pounds:_________
HEARING CONSERVATION
PLEASE ANSWER THE FOLLOWING QUESTIONS TO THE BEST OF YOUR ABILITY:
1.
How many employees does your company currently have? ________________
2.
Average new employees hired each year? _______________________
3.
How many drug/alcohol tests does your company average per year? _______________
4.
What is your average number of injuries per year? _______________
5.
How many annual/DOT/Surveillance physicals do you perform in a year? ______________
1322 E. MICHIGAN AVE, SUITE 101 LANSING, MICHIGAN 48912 (517) 364-3900 TELEPHONE
revised 102010
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Parent category: Medical