EMPLOYER ACCOUNT PROTOCOL FORM

You may choose to complete the Employer-Account Protocol Form below which when completed will be forwarded to one of our Medical Assistants for Review.

This form is in 3 parts - Please complete ALL PARTS!

If you prefer, you can click on the button below which will open a FILLABLE PDF File - complete this form, print it, and email it to aruiz.ihmg@gmail.com

Click Here to access the Employer account protocol form

Employer Account Protocol Form PART 1

Employer Account Protocol Form

Company

Mailing Address

Primary Contact Person

Secondary Contact Person

Email*

Telephone Number

Fax Number

Hours of Operation

BILLING INFORMATION

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Employer Account Protocol Form PART 2

Email*

Injury/Accident To The Employee:

Post Injury/Accident Drug Test: (Y/N)

Post Injury/Accident Breath Alcohol Test: (Y/N)

Pre-Employment Screening: Choose 1 for REGULAR; 2 for DOT; 3 for SPECIAL PACKAGE

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Employer Account Protocol Form PART 3

Email*

Pre-Employent Screening (continued)

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Industrial Health Medical Group

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