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.
Company Website
*
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Billing Information
Contact Name for Billing
*
Contact Phone Number
*
Please enter a valid phone number.
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.
TPA Fax
Please enter a valid phone number.
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.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
DER Email
*
Would you like to add another DER?
*
Yes
No
DER Name
*
DER Phone Number
*
Please enter a valid phone number.
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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Credit Card Form
Please note that Gulf Coast Occupational Medicine securely stores your credit card information on file for billing purposes. Submitting this card confirms your authorization for us to charge any outstanding invoices that remain unpaid after 90 days. No other charges will be applied without your consent, and your card will not be used for routine billing unless an invoice has gone unpaid beyond the 90-day period. All financial information is encrypted and maintained with strict confidentiality and security standards.
Type
*
Please Select
Visa
American Express
Mastercard
Discover
Name
*
Number
*
Expiration
*
-
Month
-
Day
Year
Date
Security Code
*
Submit
Should be Empty: