New Client Form
 
1.    CLIENT DEMOGRAPHICS
 Company Name:
 
 
 Company Address:
 (Street Address)
 (City, State, Zip Code)
 
 Phone:   Fax:   
 
No. of Employees:  
 		  Type of Business:

 
 
 2.    CONTACT INFORMATION
 Primary Contact Person:
 		  Title:
 
 		  Email:
 
 Phone #:   Fax #:
 
 Alternate Contact Person:  Title:
 		 Email:
 Phone #:  Fax #:
 
 
 3.    BILLING INFORMATION
 Injuries - Workers' Compensation Claims
 Billing Address:
  Billing Contact Person:
 
Title:
 Phone #:
Physicals/Drug Screens/Immunization (Non-injury) - Complete only if different
Billing Address:  Billing Contact:
 Title:                 
 Phone #:          
Other - Complete only if different
Services (i.e., Wellness Programs, Health Fair):    
 
Billing Address:                           
 
Billing Contact Person:  
 		 Phone #:
 
4.    INJURY VISIT INFORMATION
Does the company have or require:
         - modified (transitional) duty? Yes        No
         - multiple sites in South Texas?
           If yes, please list: 		Yes        No
         - drug screens on injuries? Yes        No
         - Breath Alcohol Tests on injuries? Yes        No

Return to Work Forms:
 

 Use UTMB Standard RTW Form        
 Use Client-specific RTW Form         
 
5.    PHYSICAL EXAM INFORMATION
Physical Forms:

 Use UTMB Standard Physical Form         
 Use Client-specific Physical Form            
   

Does your company perform DOT Medical Exams?                       Yes   No 
 

Completed physical is sent to:

  
  Please list what services/specific requirement your
  company has for physicals (i.e., cbc, x-rays, etc.): 
 


 Send the completed paperwork with the employee (preferred)   Yes    No
 
6.    DRUG SCREEN & BREATH ALCOHOL INFORMATION

  Forms/Kits:    Use UTMB Standard Forms/Kits          
                          Use Client-specific Forms/Kits      
 
If Client-specific Forms/Kits are used:  Employee brings kit with him/her (preferred) 
 Kits & Forms supply are kept at UTMB          
Who is your company MRO?
 
 UTMB/(physician name, if known)
  
Other: (name & address)
 
   
Send UDS to:
 		  Address:
 
Phone:
 		  Fax:
 
 
Please list who in your company can receive results via phone or mail:
 

Primary:
  
      

Phone #:   

Protocol:    Yes
                  No

Alternate 1:
   
    

Phone #:  



7.    REFERRAL INFORMATION
Referral Preferences:
Orthopedic:
Physical Therapy:
Ophthalmology:
Pharmacy:

Other client-specific information that you feel we should know to better serve you and your employees: