New Account Information
Company Name
*
Local Physical Address (Baton Rouge/Louisiana Address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Company Website
*
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Billing Information
Contact Name for Billing
*
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email Address for Invoices
*
example@example.com
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Third Party Administration
Do you use a Third Party Administration (TPA)?
*
Yes
No
TPA Company Name
*
TPA Billing Street Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
TPA Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
TPA Fax
Please enter a valid phone number.
Format: (000) 000-0000.
TPA Services
*
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Designated Employee Representatives (DERs)
Please list all individuals who are allowed to discuss confidential patient information with Gulf Coast staff
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
DER Email
*
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Test Results
Please note that all test results and records will be accessible through our online database, PureOHS. This service is completely complimentary. Designated employees will be given a login instructions.
Designated Representative Email Address
*
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Miscellaneous
So that we may better serve your needs, please give a brief description about your company:
*
About how many employees does your company employ locally?
*
Does your company work in any areas outside of our local area?
*
Yes
No
Please note that Gulf Coast Occupational Medicine offers our medical services nation-wide through our network of clinics. Would you be interested in someone contacting you to discuss this service?
*
Yes
No
Not at this time
How did you hear about Gulf Coast Occupational Medicine?
*
Which occupational medicine provider (if any) have you used previously?
*
So we may better serve you, what is motivating you to switch occupational medicine providers?
*
What made you decide to open an account with us?
*
To help us express our appreciation, please let us know who referred you.
*
Please select the medical services that your company desires:
*
Drug & Alcohol Screening
Respiratory Clearance and Fit Testing
Audiograms
Physical Examinations
Injury Management
Additional Testing (Labs, Xrays, EKGs, etc.)
Other
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