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.