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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:


  • 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.

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

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


Worker Compensation

Worker Compensation

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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.