Central Occupational Medicine Providers

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Registration

Please accomplish the form below and click on the SEND button.

EMPLOYER REGISTRATION FORM

Company Name:	Standard Industrial Classification (SIC) #:
Location Address:	City: State: Zip:
Type of Business:	Hours of Operation: # of Employees:

Does your Company use Temp/Staffing Agency? Yes No If yes, which Staffing Agency?

Corporate Name (if applicable):

Corporate Address: City: State: Zip:

INJURY CONTACT INFORMATION

Primary Contact Person:	with Location with Corporate Office
Email Address:	Phone#: CP#: Fax:
Secondary Contact Person:	with Location with Corporate Office
Email Address:	Phone#: CP#: Fax:
After Hours Contact Person:	with Location with Corporate Office
Email Address:	Phone#: CP#: Fax:

PRE-EMPLOYMENT CONTACT INFORMATION

Primary Contact Person:	with Location with Corporate Office
Email Address:	Phone#: CP#: Fax:
Secondary Contact Person:	with Location with Corporate Office
Email Address:	Phone#: CP#: Fax:

WORKER'S COMP INSURANCE CARRIER / CLAIMS ADMINISTRATOR / PEO / BILL REVIEWER INFORMATION

Is Company Self Insured? Yes No

**Company named above is assumed authorized and is responsible for payments to COMP. If not, please attach Certificate of Insurance and provide ff. information:

Insurance Carrier:	Policy #: Policy Expiration: "mm/dd/yyyy"
Mailing Address:	City: State: Zip:
Assigned Adjuster:	Phone#: Fax:
Email address:

Please provide information below if applicable:

TPA:	Claims Administrator PEO
Mailing Address:	City: State: Zip:
Assigned Adjuster:	Phone#: Fax:
Email address:

Bill Reviewer:
Mailing Address:	City: State: Zip:
Assigned Reviewer:	Phone#: Fax:
Email Address:

DRUG TEST INFORMATION - TPA OR LABORATORY USED (if applicable):

TPA:	Laboratory Used:
Attention/Send to:	Email Address: Fax:
Mailing Address:	City: State: Zip:

SERVICES PROTOCOL INFORMATION (INJURY):

Follow Written/Online Authorization if different from Company Protocol? Yes No

**Please note that properly signed AUTHORIZATION FORMS are required to be submitted for every service rendered.

Allow verbal authorization? Yes No If YES, need written authorization to follow? Yes No

Allow Pre-authorization for Durable Medical Equipment? Yes No

Do you or your Insurance Carrier use a Pharmacy Prescription Program? Yes No

Allow Transportation Authorization for Services other than First Injury? (Additional Fees may apply) Yes No

Modified Work Status Available? Yes No

Need online access for Medical Reports, Physicals, Drug Results and Account Status Report? Yes Email: No

Send Progress Note(s) / Follow Up Status through: Email: Other:

INJURY to the employee:

A. DRUG TESTING REQUIRED: Yes No Upon Request ONLY

Instant Drug Test (Quick Test) 5 Panel 10 Panel With Confirmation on Non Negative? Yes No

Drug Screen (DSS) Send to COMPs Lab NIDA NON-NIDA

Urine Collection (Drug Test) - Send to other Labs - Laboratory:

Hair Collection (Drug Test) - Send to other Labs - Laboratory:

B. BREATH ALCOHOL TEST REQUIRED: Yes No Upon Request ONLY

Special Instructions / REMARKS:

ACCIDENT OR COLLISION without injury to the employee:

A. DRUG TESTING REQUIRED: Yes No Upon Request ONLY

Instant Drug Test (Quick Test) 5 Panel 10 Panel With Confirmation on Non Negative? Yes No

Drug Screen (DSS) Send to COMPs Lab NIDA NON-NIDA

Urine Collection (Drug Test) - Send to other Labs - Laboratory:

Hair Collection (Drug Test) - Send to other Labs - Laboratory:

B. BREATH ALCOHOL TEST REQUIRED: Yes No Upon Request ONLY

Special Instructions / REMARKS:

SERVICES PROTOCOL INFORMATION (PRE-EMPLOYMENT)

PRE-EMPLOYMENT SERVICES for the employee:

A. DRUG TESTING REQUIRED: Yes No Upon Request ONLY

Instant Drug Test (Quick Test) 5 Panel 10 Panel With Confirmation on Non Negative? Yes No

Drug Screen (DSS) Send to COMPs Lab NIDA NON-NIDA

Urine Collection (Drug Test) - Send to other Labs - Laboratory:

Hair Collection (Drug Test) - Send to other Labs - Laboratory:

B. BREATH ALCOHOL TEST REQUIRED: Yes No Upon Request ONLY

Special Instructions / REMARKS:

C. PHYSICAL EXAM REQUIRED: Yes No Upon Request ONLY

Physical Description: Service Times 8:30am-4:45pm (Mon-Fri) except Holidays

Basic Biometric Physical Exam (includes Medical History Review, Medical Examination, Blood Pressure, Vitals)

Intermediate Physical Exam (includes Medical History Reviewed, Medical Examination, Blood Pressure, Vitals, Vision, Hearing, Urinalys, Audiogram)

DOT Physical/ DMV/ Drivers Exam

Return to Work (fit for duty) Physical Exam

Vision (Snellen Eye Chart)

Audiogram/Hearing

Special Instructions / REMARKS:

D. ADDITIONAL SERVICES REQUIRED: Yes No Upon Request ONLY

Back Lift Training

JAMAR (Grip Test)

Agility Lift Test LBS:

EDEX (must be done in combination with a Physical)

Nerve Pace

Pulmonary Function Test w/ Respiratory OSHA Questionnaire

Mask Fit

Respiratory Question

Chest X-Ray 1 View 2 Views

Back X-Ray 2 Views 3 Views 5 Views

Special Instructions / REMARKS:

E. INJECTIONS REQUIRED: Yes No Upon Request ONLY **(availability may be limited)**

Tetanus

T-dap

Varicella Vaccine

Hepatitis B 3 series

Flu Vaccine

PPD/ TB Test

MMR Vaccine

WORKERS COMPENSATION COMPLIANCE NOTICES

CLAIM FORM, FIRST AID

5401. (a) Within one working day of receiving notice or knowledge of injury under Section 5400 or 5402, which injury results in lost time beyond the employee's work shift at the time of injury or which results in medical treatment beyond first aid, the employer shall provide, personally or by first-class mail, a claim form and a notice of potential eligibility for benefits under this division to the injured employee, or in the case of death, to his or her dependents.

As used in this subdivision, "first aid" means any one-time treatment, and any follow-up visit for the purpose of observation of minor scratches, cuts, burns, splinters, or other minor industrial injury, which do not ordinarily require medical care. This one-time treatment, and follow-up visit for the purpose of observation, is considered first aid even though provided by a physician or registered professional personnel."Minor industrial injury" shall not include serious exposure to a hazardous substance as defined in subdivision(i) of Section 6302. The claim form shall request the injured employee's name and address, social security number, the time and address where the injury occurred, and the nature of and part of the body affected by the injury. Claim forms shall be available at district offices of the Employment Development Department and the division. Claim forms may be made available to the employee from any other source.

PROVISION OF CARE and LIABILITY FOR CLAIM

5402. (a) Knowledge of an injury, obtained from any source, on the part of an employer, his or her managing agent, superintendent, foreman, or other person in authority, or knowledge of the assertion of a claim of injury sufficient to afford opportunity to the employer to make an investigation into the facts, is equivalent to service under Section 5400.

(b) If liability is not rejected within 90 days after the date the claim form is filed under Section 5401, the injury shall be presumed compensable under this division. The presumption of this subdivision is rebuttable only by evidence discovered subsequent to the 90-day period.

(c) Within one working day after an employee files a claim form under Section 5401, the employer shall authorize the provision of all treatment, consistent with Section 5307.27, for the alleged injury and shall continue to provide the treatment until the date that liability for the claim is accepted or rejected. Until the date the claim is accepted or rejected, liability for medical treatment shall be limited to ten thousand dollars ($10,000).

d) Treatment provided under subdivision (c) shall not give rise to a presumption of liability on the part of the employer.

Acknowlegement:

Submitted by:

Date:

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