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
Main Contact Person

First NameLast Name
Title
Main Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Main Contact Email
example@example.com
Tax ID#
DOT# (for DOT regulated companies)
Billing

WE PREFER EMAILING INVOICES. PLEASE PROVIDE ACCOUNT PAYABLES EMAIL ADDRESS.
How would you prefer to receive invoices?
AP Email
example@example.com
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Worker's Comp Carrier Information
Worker's Comp Carrier Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Services
Please Select ALL services that will be needed.
IF NON-DOT drug screen is needed. Select ONE drug screen panel to use.
If you have your own Service request paperwork that will be sent in with the patient, please attach it here for reference.

Cancelof
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 accessable to the following personnel.
Would you like to access your results through our convenient portal? (If NO, results will be emailed to you.)
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
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Important Portal, Screening, and Lab Information
Thank you for partnering with Louisiana Occupational Health Services for all your employees health and wellness needs. Please read the important information below.

Portal Documents
- If your company is utilizing our portal for resutls and documents, please allow up to 24 hrs for documents to be uploaded.
- If you are using LOHS's MRO and lab, you will be notified in the portal when the collection is complete and another when the drug screen result is ruled and closed.
- If a collection has not resulted within 72 hours, this means it is still processing and the Dr. has not ruled on the result. Please allow more time, or call (318)561-8200 to let us check into the status.
Drug Screens/ Labs - Resulting Time Frames
- Drug screen results typically take up to 72 hours to receive the preliminary result back from the lab.
- In some case, preliminary results can take longer if the lab has to send it through a confirmation process.
- Once LOHS's MRO (Dr.Webb) receives the prelimenary result; it will either be resulted negative or non-negative.
  If it comes back from the lab as a non-negative, Dr. Webb has 3 call in 10 days to reach the patient and make his ruling.
- Hair testing can take up to a week to receive the prelimenary results.
Labs
- Most labs will result with-in 24-48 hours.
- Some labs such has some Hormone panels and TB Gold can take up to 72 hours.
Louisiana Occupational Health Services - 3018 Jackson St., St. 100, Alexandria, LA 71301

P:(318)561-8200 F:(318)561-8204 www.lohs.net
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Occupational Health Account Information

Billing

Worker's Comp Carrier Information

Services

Restricted Release Information

Important Portal, Screening, and Lab Information