LOHS Occupational Health Set-Up

Occupational Health Account Information

Louisiana Occupational Health Services
Company Name*
DBA
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Contact Person*

First NameLast Name
Title
Tax ID#
DOT# (for DOT regulated companies)
BILLING

WE PREFER EMAILING INVOICES. PLEASE PROVIDE ACCOUNT PAYABLES EMAIL ADDRESS.
AP Email (mandatory)*
example@example.com
Billing Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Worker's Comp Carrier Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Restricted Release Information

I authorize the below personnel, ONLY, to obtain employee medical information and/or drug screen results via email, fax, and/or verbal reports from Louisiana Occupational Health Services. I confirm the below personnel will maintain confidentiality with regards to any and all reports received. The company agrees to update this form in the event any authorized personnel changes are made. All medical information and drug screen results will be EMAILED to the following personnel.
Authorized Personnel to receive Employee Medical Information*

First NameLast Name
Email for results to be sent to.*
example@example.com
Authorized Representative *

First NameLast Name
Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Louisiana Occupational Health Services - 3018 Jackson St., St. 100, Alexandria, LA 71301

P:(318)561-8200 F:(318)561-8204 www.lohs.net
Should be Empty:

Occupational Health Account Information

BILLING