Client companies served by Cooper Clinic Occupational Medicine are asked to provide the information below. Your cooperation is greatly appreciated. NOTE: You can “cut and paste” a field of text into another when information is to be duplicated.
Company Name:
Physical Address:
City: State: Zip:
Authorization 1: Email:
Authorization 2: Email:
Primary Contact Person:
Phone: Fax:
Email Address:
Billing Information
Billing Name:
Billing Address:
Accounts Payable Contact Person:
Phone Number: Fax Number:
Results and Other Information
Does Company Use Own Physical Forms?: Yes No
Can results be faxed? Yes No If yes, provide the fax number:
Do you want physical exam results to be mailed? Yes No If yes, mail to: Name: Address: City: State: Zip:
Give to Employee?: Yes No Other Instructions:
Do you want DOT physical results to be mailed? Yes No If yes, mail to: Name: Address: City: State: Zip:
Give to Employee: Yes: No: Other Instructions:
DOT LAB: Account Number:
NON DOT LAB: Account Number:
Are we the MRO? Yes No If NO who is the MRO?
MRO Address:
Where should the company Chain Of Custody form be sent? Fax: Send with employee Mail to: Address: City: State: Zip:
Will Employee Bring Form?: Yes: No:
Results mailed to:
Name: Address:
Contact 1: Phone: Email :
Contact 2: Phone: Email :
Post Accident Do You Require: Drug Screen: Yes: No: Breath Alcohol: Yes: No:
Authorization Contact Person 1: Email Address: Phone: Fax:
Authorization Contact Person 2: Email Address: Phone: Fax:
Name of insurance carrier:
Address:
Insurance Carrier Contact Person:
Where should workers comp form be sent? Fax: Send with employee Mail to: Address: City: State: Zip:
Strong Medicine.
25 Specialties. 16 Locations. Since 1920.