Business & Contact Information
Legal Business Name (as listed on W-9)
*
Industry or Business Type
(e.g., construction, retail, medical staffing)
Main Office Phone Number
*
Format: (000) 000-0000.
Primary Worksite Location
*
(Street, City, State, Zip)
Billing Address (if different from worksite)
Company Fax Number
Approximate Number of Employees
Primary Contacts & Portal Admin
List your main point of contact and the admin for CoworkHealth Portal access.
Primary Company Contact - Full Name
*
Full Name
Primary Contact Phone Number
*
Direct mobile or office line.
Format: (000) 000-0000.
Primary Contact Email
Email address for scheduling updates or questions.
CoworkHealth Admin – Full Name
Full Name
Admin Contact Phone Number
Format: (000) 000-0000.
Admin Contact Email Address
Email to receive CoworkHealth login credentials.
Billing Contact & Invoice Setup
Provide billing contact details and where to send invoices.
Billing Contact – Name
Full name
Billing Contact – Phone Number
Billing Contact – Email Address
example@example.com
Services Requested
Select all services you would like us to provide for your employees. If a service is not listed, please write it in the 'Other' section.
Physical Exams
Physicals - Pre Employment
Physical DOT
Return-to-work Evaluations
Drug Testing
Drug Testing - Non DOT - Rapid
Drug Testing - Non DOT - Lab
Drug Testing - DOT - Lab Only
Alcohol Testing
Breath Alcohol Test - DOT
Breath Alcohol Test - Non DOT
Infectious Disease / Immunizations
TB Skin Test (PPD)
TB - QuantiFERON-TB Gold
Other Services
Mask Fit Testing - Qualitative
Other
Workers’ Compensation Insurance & Injury Visit Preferences
Add your WC insurance details and let us know how you'd like us to handle first-visit testing.
Workers' Compensation Insurance Carrier
Insurance company name
Workers' Compensation Insurance Carrier
Street Address or P.O. Box, City, State, ZIP
WC Policy Number
WC Carrier Phone Number
Format: (000) 000-0000.
WC Carrier Fax Number
Format: (000) 000-0000.
Policy Start Date (MM/DD/YYYY)
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Policy Expiration Date (MM/DD/YYYY)
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Testing Performed at First Injury Visit (Check all that apply)
DOT Drug Test
Rapid 10-Panel Drug Test
Breath Alcohol Test
None - Evaluate without alcohol and drug test
Should we notify you if any test is positive before proceeding with evaluation?
Yes
No
Do we have permission to dispense Durable Medical Equipment (DME) if needed for injury?
Yes
No
Additional WC Instructions
Employee Visit Notifications
Let us know when you’d like to be notified about missed or incomplete visits.
Would you like to be notified if an employee misses their appointment (initial or follow-up)?
Yes
No
Should we notify you if a visit is incomplete and the employee leaves before seeing a provider?
Yes
No
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