Client Set Up Form
Employer client setup form for Unidad Medica Santa Maria Valley. Complete all required fields.
Employer Information
Employer Name
*
Employer Address
*
Business Type
Number of Employees
Hours of Operation
Billing Contact Information
Employer Billing Contact Name
*
First Name
Last Name
Billing Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Billing Email Address
*
example@example.com
Billing Fax Number
Authorization and Results Contact Information
Employer Authorization and Results Contact Name
*
Authorized Contact Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Authorized Contact Email Address
*
example@example.com
Authorized Contact Fax Number
Authorized Services
Service(s) Authorized
*
Pre-Employment Physical
DOT Physical
Return-to-Work Physical
Annual Physical
Drug Screen
Breath Alcohol Test
TB Test
Audiogram
Pulmonary Function Test
Respirator Clearance
Fit Testing
OSHA Questionnaire
Other
Other (please specify)
Date
*
-
Month
-
Day
Year
Date
Authorized Employer Contact Name
*
First Name
Middle Name
Last Name
Authorized Employer Signature
*
Submit
Submit
Should be Empty: