Before You Begin

STOP: This form is to be completed by authorized personnel only. To avoid delays or incomplete submissions, please ensure you have the following information ready before launching the form.

What You'll Need:

  • Billing Information – including billing address, and contact name for those generating Purchase Orders (PO's).
  • Written Medical Protocols – if applicable to your request.
  • Designated Employer Representative (DER) Contact Email and Phone Number – for form processing and follow-up.

Incomplete forms cannot be processed and may result in service delays. When you have ALL of the required information, click below to proceed.

  • Below Line For Office Use Only

  • * If you do not receive a confirmation by phone within 24 hours, please call PRIME On-Site to confirm. 225-408-5902 ext.234

Please contact Business Development for further information regarding Custom Client Forms.
(225) 408-5902 | [email protected]