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
- If not applicable choose N/A. See the question below.
  - N/A
- Worker’s Comp. Insurance Company:*
- Insurance Address:*
- Insurance Phone #:*
- Insurance Fax #:*
Third Party Administrator (TPA)
- Company Name:
- Billing Address:
Human Resources Department
- HR Main Contact:*
- Phone:
- Secondary Contact:
- Phone:
- 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
  - Baytown (Must also be a member of ISTC)
- 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