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General Information

Today's Date:

Now

How did you hear about us? *:

Services Requested

Service Requested

Types of Services Requested (select all that apply) *:

Annual Surveillance
Bus Driver Physical Exams
DOT Physical Exams
Drug Testing
Fire/Police Physical Exams
Fit for Duty/Return to Work
Pre-Employment Physicals
Respirator: Questionnaire Review/Clearance and/or Fit Testing (because of COVID)
Work Injury Management
Other

If Other:

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

All below locations
Bangor, Maine (885 Union Street, Suite 215)
Dover Foxcroft, Maine (47 Dwelley Avenue)
Ellsworth, Maine (32 Resort Way)
Pittsfield, Maine (125 Main Street)
Portland, Maine (43 Baxter Blvd, Suite 220)
Presque Isle, Maine (19 North Street)
Waterville, Maine (246 Kennedy Memorial Drive, Suite 202)

Primary Contact

Primary Contact Name and Title *:

Primary Contact Phone *:

Primary Contact Secure Fax *:

Primary Contact Email *:

Primary Contact to Receive the Following Post-Visit Documentation:

M1 Form
Clearance Form
Chain of Custody Form

M1 - M1 is a diagnostic medical report that is for Maine Workers' Compensation Board.
Chain of Custody - Chain of Custody and Control form, COC is also known as CCF form, which is a form used to document the donor specimen from time of collection at the collection site, to the laboratory, and to reporting the final result from the Medical Review Officer.

Preferred Method of Receiving Post-Visit Documentation *:

Secondary Contact

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

Secondary Contact Name and Title:

Secondary Contact Phone:

Secondary Contact Secure Fax:

Secondary Contact Email:

Secondary Contact to Receive the Following Post-Visit Documentation:

M1 Form
Clearance Form
Chain of Custody Form

Secondary Preferred Method of Receiving Post-Visit Documentation:

Billing Information

Please provide any special instructions regarding company contact(s) and communication *:

Billing Contact Name and Title:

Company Billing Address (If different from above):

Do you utilize a Third Party Administrator for Urine Drug Testing/Breath Alcohol Testing? *:

Yes
No
N/A

Please indicate who should be billed for Urine Drug Screen Testing:

Please indicate who should be billed for Breath Alcohol Testing *:

Worker Compensation

Worker's Compensation Carrier Name *:

Worker's Compensation Carrier Mailing Address *:

Policy Number *:

Policy Effective Date *:

Now

Policy Expiration Date *:

Now

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.

Electronic Signature *:

Date *:

Enter security code:

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+1 (844) 975-4584
workhealth@northernlight.org

Create Account

General Information

General Information

Company Information

Company Information

Services Requested

Service Requested

Primary Contact

Primary Contact

Secondary Contact

Secondary Contact

Billing Information

Billing Information

Worker Compensation

Worker Compensation

Electronic Signature

Electronic Signature