Setup Account

Company Information
- Company Name:*
- Company Physical Address:*
- City:*
- State:*
- Zip:*
Billing Information
- Accounts Payable Contact Person:*
- Billing Address:*
- Email Invoices?*
  - Yes
  - No
- Would you like to pay by direct deposit?*
  - Yes
  - No
- Invoice Email Address:*
- Phone:*
- Fax:*
Tax ID OLD:
Tax ID:*
Worker’s Comp. Information
- Worker’s Comp. Insurance Company:*
- Insurance Address:*
- Insurance Phone #:*
Third Party Administrator (TPA)
- Company Name:
- Billing Address:
Human Resources Department
- HR Main Contact:*
- Phone:
- Secondary Contact:
- Phone:
- Email Results?
  - Yes
  - No
- Email*
- 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 in Louisiana? 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
  - Beaumont (Must also be a member of ISTC)
  - On-Site
- 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)
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