OCCUPATIONAL MEDICINE COMPANY PROFILEPage 2 of 2 REVISE DATE: 07/19/2016 OCCUPATIONAL MEDICINE COMPANY PROFILE P: 808.456.CARE (2273) |E: [email protected] W: …

Page 1 of 2 REVISE DATE: 07/19/2016

OCCUPATIONAL MEDICINE COMPANY PROFILE P: 808.456.CARE (2273) |E: [email protected] W: www.ucarehi.com

Company Name:__________________________________________________ Contact Name:___________________________________________

Company Address:_____________________________________________________________________________________________________________ Street Address City/State/Zip

Phone Number:___________________________________________ Fax Number:______________________________________________________

Authorization List:_____________________________________________________________________________________________________________

BILLING INFORMATION

Do you want your statement printed? Yes No

How would you like your statement printed? Summary (All employees on a single page)

Detailed (Each employee on a single page)

Both

Would you like to include SSN on statement? Yes No

WORKERS COMPENSATION/WORK-RELATED INJURY INFORMATION

Is your company self-insured? Yes No

*If no, please fill out the following information

Name of WC Insurance Company:______________________________________________________________________________________________

Address:_________________________________________________________________________________________________________________________ Street Address City/State/Zip

Contact Name(s):_______________________________________________________________________________________________________________

Contact Number:_________________________________________________ Fax Number:________________________________________________

EMPLOYEE PAID SERVICES (EPS) INFORMATION

How would you like to pay for the services? Employee Employer Company HR Company Headquarters * If address is same as company address above, you may leave the mailing section blank.

Mailing Address:________________________________________________________________________________________________________________

Street Address City/State/Zip

Contact Name:_____________________________________________ Contact Number:__________________________________________________

Payments will be made attention to:___________________________________________________________________________________________

*HOW WOULD YOU LIKE US TO SEND THE RESULTS (CHECK ALL THAT APPLY)?

Fax

Mail

Email

Employer Portal

*By selecting the Employer Portal you will be provided with a username and password to the indicated email address below and a how-to hand out.

Mailing Address:________________________________________________________________________________________________________________ Street Address City/State/Zip

Email:______________________________________________________________ Email password:___________________________________________ *To access results, please provide us with a customized six character password.

Fax Number:_______________________________________________________ Attention to:_______________________________________________

LOCATION OF INTEREST: KAPOLEI KAILUA PEARL CITY WAIKIKI Please select all that apply

Page 2 of 2 REVISE DATE: 07/19/2016

OCCUPATIONAL MEDICINE COMPANY PROFILE P: 808.456.CARE (2273) |E: [email protected] W: www.ucarehi.com

EMPLOYER PAID SERVICES (EPS) SERVICES REQUESTED

Physicals: Yes No Please select all that apply: Non-DOT DOT/CDL/PUC Medical Card Basic

Reason for Physical: Pre-Employment Return-to-Work/Fit-for-Duty

Drug Screening: Yes No Please select all that apply: Non-DOT Panel 5 DOT Panel 5

Non-DOT Panel 10 Instant Panel 5

DOT Drug Collection *Only *Chain of Custody Form must be LabCorp

Drug Testing Medical Review Officer (MRO) Services: Use Company MRO Provide own MRO *Chain of Custody Form must be LabCorp

Name of MRO:_________________________________________________________________________________________________________

Address of MRO:_______________________________________________________________________________________________________ Street Address City/State/Zip

Phone Number:___________________________________________ Fax Number:_______________________________________________

Immunizations: Yes No Please select all that apply: Tetanus Flu TB/PPD MMR

Hepatitis B Series (Series of 3 shots)

Hepatitis A (Series of 2 shots)

Laboratory: Yes No Please select all that apply: Urinalysis CBC Zinc Protoporhin

(Collection only – please note prices are subject to change based on DLS) Lead Heavy Metal

Procedures: Yes No EKG

Respirator: Yes No Please select all that apply: Respirator Clearance (*Will proceed to Respirator Physical Exam if employee fails Respirator Questionnaire) Respirator Physical Exam

Qualitative Respirator Fit Test (*employee to provide resp. mask)

Alcohol Testing: Yes No Please select all that apply: DOT

Other Special Instructions:

__________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________

LOCATIONS PEARL CITY

1245 Kuala Street, St 103 Pearl City, HI 96782

P: 808.784.2273 F: 808.456.2274

KAPOLEI 890 Kamokila Blvd., Suite 106

Kapolei, HI 96707 P: 808.521.2273 F: 808.521.2274

KAILUA 660 Kailua Road Kailua, HI 96734 P: 808.263.2273 F: 808.263.2274

WAIKIKI 1860 Ala Moana Blvd., #101

Honolulu, HI 96815 P: 808.921.2273 F: 808.921.2274