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PRIME Occupational Medicine > Forms

Forms

Setup Account
On-Site Service Request
Medical Authorization
Custom Client Form

Setup Account

Company Information
- Company Name:*
- This field is hidden when viewing the form
  Company Physical Address:
Company Physical Address*
Street Address City State / Province / Region ZIP / Postal Code Country
- This field is hidden when viewing the form
  City:
- This field is hidden when viewing the form
  State:
- This field is hidden when viewing the form
  Zip:
Billing Information

- Invoices will be emailed or faxed to secure line, unless otherwise requested in writing. Request should be sent to invoices@primeoccmed.com.
- Accounts Payable Contact Person:*
- Billing Address:*
- An email address is required for invoice notifications. We strongly recommend a department address i.e. ap@yourcompany.com
- Invoice Email Address:*
- Accounts Payable Phone:*
- Fax:*
This field is hidden when viewing the form
Tax ID OLD:
Tax ID:*
Will you be submitting payment via ACH? (Preferred Method)*
- Yes
- No
Worker’s Comp. Information

- If not applicable choose N/A. See the question below
  - N/A
- Invoice Options for Worker's Compensations Claims
  - Invoice directly to Worker's Comp Carrier (details provided below)
  - Invoice directly to Employer AP Contact (by traditional invoice)
  - Invoice directly to Employer AP Contact (by Insurance Claim form, Employer is responsible for filing claim to carrier and payment)
- Worker’s Comp. Insurance Company:*
- Insurance Address:*
- Insurance Phone #:*
- Insurance Fax #:*
Third Party Administrator (TPA)

- Company Name:
- Billing Address:
Human Resources/Risk Management

- HR Main Contact:*
- Phone:
- Secondary Contact:
- Phone:
- Email*
- Physical Address
  Street Address City State / Province / Region ZIP / Postal Code Country
- This field is hidden when viewing the form
  Physical Address
Safety and Injury Management

- Injury Management Contact:
- Phone:
- Safety Manager(s):
- Phone:
- Safety Manager(s):
- Phone:
- Post-Incident Drug Screen:
  - DOT
  - Non-DOT
  - Quick
- Panel of Test:
Breath Alcohol:
- DOT
- Non-DOT
We will keep you up to date with PRIME Occupational Medicine’s monthly news and OSHA updates. Please list your appropriate staff and email addresses below. Thank You!
- Name:
- Email:
- Name:
- Email:
- Name:
- Email:
Account Profile

- First and Last Name of responsible manager for services related questions?
- Office Phone:
- Cell Phone:
- Email:
- Which services does your company have protocols? Check all that apply:
  - Select All
  - Drug Screen
  - Physical Exam
  - Fit-for-Duty Exam
  - Injury Treatment
  - Case Management
  - Hearing Conservation
  - Respirator Fit
  - Wellness Program
  - On-Site Services
- Other
- Please indicate PRIME's services that your company intends to use. Check all that apply:
  - Select All
  - Drug Screen
  - Physical Exam
  - Fit-for-Duty Exam
  - Injury Treatment
  - Case Management
  - Hearing Conservation
  - Respirator Fit
  - Wellness/ Health Risk/Vaccinations
  - On-Site Services
  - In-House Medical Staffing
  - Telemedicine/EME
- Other
- What is the approximate number of people that your company employs locally? Choose one.
  - 1-10
  - 11-50
  - 51-100
  - 101-250
  - 251-500
  - 501-1000
  - 1001-1500
  - 1501-2500
  - 2501-5000
  - 5000+
- What is the approximate number of people that your company employs nationwide? Choose One.
  - 1-10
  - 11-50
  - 51-100
  - 101-250
  - 251-500
  - 501-1000
  - 1001-1500
  - 1501-2500
  - 2501-5000
  - 5000+
- Please indicate PRIME's clinic locations that you plan to utilize. Check all that apply:*
  - Select All
  - All Locations
  - Baton Rouge/Prairieville
  - Port Allen/Brusly
  - Chalmette/New Orleans
  - Reserve/Laplace
  - Sulphur/Lake Charles
  - Lafayette
  - Port Arthur, TX
  - On-Site
  - Baytown (North Main)
  - Portland, TX
- What is the nature of your business? Check all that apply:
  - Select All
  - Contractor
  - Plant/Refinery
  - Service
  - Transportation
  - Commercial/Retail
  - Government
- Other:
- How did you hear about us? Choose One:
  - Website
  - DISA Referral
  - Contractor Referral
  - Marketing Representative
  - Networking Event
- If a Marketing/Sales Representative contacted you initially, please type the person’s name below
Designated Employer Representative (DER)
Your company's DER will be responsible for managing your employee screening results and will have access to these results on PRIME's online portal.

Name
First Last
- Phone
- Email
** If you do not receive a confirmation within 24 hours, please call PRIME's Account Manager to confirm. 225-408-5902

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On-Site Service Request

- Date(s) of Service:*
- Company:*
- Location(s) of On Site Work:*
- Requested Time(s):*
- Requested by:*
- Phone Number*
- Email:*
- Tests Needed:
  - Drug Screens
  - Breath Alcohol
  - Physicals
  - Audio
  - Pulmonary
  - Fit Tests
  - Flu Shots
  - Other
- Drug Screens Type & # of Tests
- Breath Alcohol Type & # of Tests
- Physicals Type & # of Tests
- Audio Type & # of Tests
- Pulmonary Type & # of Tests
- Respirator Fit Test:
  - Quantitative (PortaCount)
  - Qualitative (Odor Test)
- Mask #1:
- - Half-face
  - Full-face
- Mask #2:
- - Half-face
  - Full-face
- Mask #3:
- - Half-face
  - Full-face
- Flu Shots Type & # of Tests
- Other Type & # of Tests
- Accomodations Needed
  - Tests will be performed using our facilities.
  - Prime will provide mobile medical unit(s).
- How would you like to receive your PRIME On-Site results?
  - Individual
  - Collated Binder
Below Line For Office Use Only
Technician(s) Needed:
Notes:
* If you do not receive a confirmation by phone within 24 hours, please call PRIME On-Site to confirm. 225-408-5902 ext.234

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Medical Authorization

Please select a Clinic Location:*
- Baton Rouge
- Port Allen
- Reserve (LaPlace)
- Chalmette (N.O. East)
- Lafayette/Broussard
- Cities Service Highway (Sulphur)
- Baytown (North Main)
- Port Arthur
- Portland
Baton Rouge, LA*
- Launch Form
- Download Form
15475 Airline Highway Baton Rouge, LA 70817 Fax: 225-778-7542
Baytown, TX (North Main)*
- Launch Form
- Download Form
4404 N Main St. Baytown, TX 77521 Fax: 281-628-7010
Port Arthur, TX*
- Launch Form
- Download Form
3820 Hwy 365 Ste 500 Port Arthur, TX 77642
Port Allen, LA*
- Launch Form
- Download Form
3515 LA Highway 1 S Port Allen, LA 70767 Fax: 225-749-3138
Laplace, LA (Reserve)*
- Launch Form
- Download Form
3584 West Airline Highway Reserve, LA 70084 Fax: 985-536-3919
Chalmette, LA (N.O. East)*
- Launch Form
- Download Form
303 W. Judge Perez Chalmette, LA 70043 Fax: 504-570-6353
Lafayette, LA (Broussard)*
- Launch Form
- Download Form
106 Heritage Parkway, Broussard, LA 70518 Fax: 337-237-8666
Sulphur, LA (Cities Service Hwy)*
- Launch Form
- Download Form
2492 S Cities Service Hwy Suite 1 Sulphur, LA 70665 Fax: (337) 905-1963
Portland, TX*
- Launch Form
- Download Form
1500 Wildcat Dr. Suite M Portland, Texas 78374
Click to Download Form
Click to Download Form
- Employee Name:*
- Social Security #:*
- Company:*
- Company Contact Name:*
- Job Site/Job Number:
- Injury Treatment:
- Job Description:
Reason:*
- Pre-Placement
- Annual
- Semi-Annual
- Recertification
- Post Accident
- Random
- Other
Please Specify:*
Physical Exam:
- DOT
- Non-DOT
- Hazmat
- Asbestos
- Operator
- OGUK (By appointment ONLY)
- Offshore
- Other
Please Specify:*
Physical Performance Test:
- Pre-Placement
- Other
Please Specify:*
Breath Alcohol:
- DOT
- Non-DOT
Observation/Witness Collection:
- Yes
- No
Drug Screen:
- 5 Panel (Quick)
- 10 Panel (Quick)
- 12 Panel (Quick)
- Prime Non-DOT
- Prime DOT
- Synthetic Marijuana
- Synthetic Opioid
- PHMSA
- USCG
- FMSCA
- Other
Please Specify:*
Hair Test:
- Prime Hair Test (5 panel)
- Other
Please Specify*
DISA:
- BAT Non-DOT
- BAT DOT
- FMSCA
- Urine DOT
- PHMSA
- Urine Non-DOT
- Hair Test
- USCG
- Oral Non-DOT
- DISA Policy/Account:
- Other Lab:
Respirator Fit Test:
- Quantitative (PortaCount)
- Qualitative (Odor Test)
- Mask #1:
- Mask #2:
- Mask #3:
Check all that apply
- Pulmonary Function Test
- Medical Record Evaluation
- Audiogram
- Titmus Vision Testing
- Return to Work Clearance
- Fit for Duty Clearance
- Safety Evaluation
- TB Skin Test (Employee must be able to return to the clinic within 2-3 days to have test read)
- Laboratory Tests
Add STS Comparison?
- Yes
- No
Laboratory Tests:*
Other Tests
Authorized Signature*
- Phone*
- Email*

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Custom Client Form

Please contact Business Development for further information regarding Custom Client Forms.
(225) 408-5902 | bus.dev@primeoccmed.com

PRIME Occupational Medicine is committed to providing the highest quality of occupational medicine care.

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Clinic:
225.749.5750

Corporate Headquarters:
225.408.5902

Email:
admin@primeoccmed.com
Clinic Hours:
Mon - Fri 7:30am - 4:30pm

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