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General Information

General Information

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Company Information

Company Information

Services Requested

Service Requested

Types of Services Requested (select all that apply):







Please select the Work Health location(s) your company will utilize:






Primary Contact

Primary Contact

Primary Contact to Receive the Following Post-Visit Documentation:


Secondary Contact

Secondary Contact

If your Company does not have a secondary contact, please skip this section.

Secondary Contact to Receive the Following Post-Visit Documentation:


Billing Information

Billing Information

Worker Compensation

Worker Compensation

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Now

Electronic Signature

Electronic Signature

Work Health will bill Employer's worker's compensation carrier directly for all occupational health services provided, for work-related injuries. In the event the carrier denies coverage, Employer understands and agrees that Employer shall be responsible for paying all charges associated with WorkHealth's services.