Connect With Us
Contact Us
Employers
Complete the form below to set up your company with ProActive Work Health Services. Our team will follow up within one business day.
Company Information
Company Name/DBA
Location #
Type (Corp/LLC/Sole Proprietor/Franchise)
Phone Number
Fax
Website
# of Employees
Address
City
State
Zip
Company Leadership (President/CFO/CEO)
Industry
Hours of Operation
Holidays Observed
Other Locations (attach a copy if individual set up is required)
Injury Care Contact Information
Contact 1
Name
Title
Direct Line/Ext
Cell Phone
Injury Reports Fax/Portal/Email address
Contact 2
Additional Contacts
Workers Comp Insurance Carrier / Injury Billing Instructions
Workers' Compensation Insurance Carrier
Policy #
Address or PO Box
Phone #
Effective Date
Exp.
Adjuster
Phone
Email/Fax
RX Program
BIN #
Group #
Third Party PEO Name
Injury Billing Preference
Injury Billing Contact Name
Email
Mailing Address (if different than above)
Modified Duty Available
If Yes, For (Days)
Post Accident Drug Testing
Drug Testing Results/DER Contact Name
Drug Testing Invoices Email Address
ProActive Locations
California
Texas
Arizona
Third Party Administrator Services
TPA Name
TPA Phone Number
National Acct#
TPA Billing Address
ST
DOT Program Manager Name
Employer Paid Services
Company Name
Billing Contact
Phone#
Billing Address
Drug & Alcohol Testing Options
Results to
Examination Options
ADD TO BASIC P.E.
Lifting Test Options
Physical Abilities Lift Test – 3x lift with (pounds), from ground to 30" (table top)
Medical Surveillance Testing
Vaccines/Labwork
Vision Testing
Other
Terms
By signing below, I certify and agree to the following: 1) I am an authorized agent of the company named above (Company) and I have the authority to designate company protocol(s) for services rendered by ProActive Work Health Services (ProActive). 2) HIPAA and all other relevant state, federal, and local ordinances will be enforced by the Company. 3) Company agrees to report all accidents to their insurance company as required by state, local or federal law, or within a minimum of Thirty (30) days of the initial visit with ProActive. 4) Claim numbers and all insurance information is to be provided to ProActive within Five (5) business days of receipt to the Company. 5) All non-industrial conditions, unreported accidents, First-Aid claims, denied claims will become 100% collectible from the Company. 6) All invoices for medical services that are unpaid, see item (5), will be paid in full to ProActive within Thirty (30) calendar days of receipt of invoice. 7) Written authorization presented at the time of service or in the form of email or fax will be required to provide services at ProActive Work Health within Five (5) business days of the initial visit.
Signature
Printed
Date
ProActive Rep
Patient Account #
A New Era for Occupational Work Health
Call Us (866) 30-HEALTH
