Company Profile Form

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COMPANY PROFILE FORM

Conservative Care Occupational Health

Any questions, contact Cynthia Jackson, 479-725-3044 , cjackson@ccohusa.com or Victoria Hernandez, 479-725-3008, vhernandez@ccohusa.com

New Company

Company Update

Company Name:*

Address:

City:

State:

Zip:

Phone:

Fax:

Secure Fax:

Yes

# of employees:

AUTHORIZED POINT OF CONTACTS The following will be able to schedule appointments and receive results if requested

1. Name:

Phone:

E-mail:

2. Name:

Phone:

E-mail:

3. Local contact (if not listed above):

Phone:

E-mail

BILLING Check one

E-mail

Fax

Call for Credit Card

USPS

Company:

Attention:

Phone:

E-mail:

Fax:

Address:

City:

State:

Zip Code:

WORKERS COMP CARRIER:

Policy #:

Address:

City:

State:

Zip Code:

Phone:

Fax:

CCOH sends WC bills directly to WC insurance carrier indicated above unless marked below
Work related injury bills send to:

Employer

*ALL THE WC BILLING PER THE ARKANSAS FEE SCHEDULE

OCCUPATIONAL SERVICES

DRUG SCREENS

NO DRUG SCREENING

DOT drug screens

NonDOT drug screens

Hair drug screens

Our lab & MRO

Collection only

You send in a supply of chains

Employee will bring chain

PHYSICALS

NonDot physicals

DOT physicals

Respiratory physicals

Hazmat physicals

Police physicals

Miscellaneous

Audiogram

Spirometry

Mask Fit Test

Breath Alcohol Screening

EKG

Chest X-ray

TB Skin Test

Hepatitis B Injection

Hepatitis B Titer

Flu Vaccine

If not listed above, please indicate:

RESULTS SENT:

Secure Fax:

E-mail:

Please complete, sign and return, authorizing CCOH to perform the services checked above.

Signature:

Title:*

Date:

Please sign your name above and save signature, and then submit the form below.

Select Location*