Athens Regional FirstCare

RFC Services

Occupational Medicine

Occupational Health Services

Occupational Medicine Company Profile:

Company Name
Non-Worker's Comp Company Billing Information
Address
City
State / Zip	/
Phone / Fax	/
After Hours Contact Phone Number
E-mail
Company Contact
Backup Contact
Worker's Compensation Billing Information
Carrier's Name
Address
City
State / Zip	/
Phone / Fax	/
After Hours Contact Phone Number
E-mail
Company Contact
Backup Contact
Please answer the following questions
Does the company have a drug policy?
Yes No
If so, what type of drug screen do you require?
DOT (Federal) Non-DOT Collection only (Your Lab)
If so, wht lab do you use?

Does the company have an alcohol policy?
Yes No
If so, what type of BAT do you require?
DOT Non-DOT
Does the company want employees to be screened for drug/alcohol their during visit?
Pre-employment only Post accident only All visits
Who would you like us to notify of drug screen results?

Who is a back-up contact?

How would you like to receive the drug results?
Phone Secured Fax Mail
Who would you like us to bill for drug/alcohol testing?
Bill Company: Yes No
Bill WC Insurance Company: Yes No
Does your company prefer a specific medical/surgical specialist?
Yes No
If yes, please list the names by specialty:
Orthopedics:
Plastic Surgery:
General Surgery:
Radiology:

The form will be securely transmitted to RFC's Occupational Medicine contact.

This page last modified: May 05, 2006
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