New Company Setup
ASPIRUS BUSINESS HEALTH
Company Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Contact
*
First Name
Last Name
Title
*
Phone Number
*
-
Area Code
Phone Number
Extension (if applicable)
Fax Number
-
Area Code
Phone Number
Email
*
example@example.com
Employee Count
Is billing information the same as above?
*
YES
NO
Billing Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Contact
First Name
Last Name
Title
Phone Number
-
Area Code
Phone Number
Extension (if applicable)
Fax Number
-
Area Code
Phone Number
Email
example@example.com
Is the customer set up with a lab?
YES (customer supplied COC)
NO (use Aspirus lab, paperwork, kits)
Designated Employer Representative (DER)
First Name
Last Name
Title
Phone Number
-
Area Code
Phone Number
Extension (if applicable)
Fax Number
-
Area Code
Phone Number
Email
example@example.com
Results Handling
Secure Email
Secure Fax
TPA (Third Party Administrator)
iSystoc (Electronic Resulting)
Company Work Comp Contact
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Extension (if applicable)
Fax Number
-
Area Code
Phone Number
Email
example@example.com
WC Insurance Carrier
Additional Information
Please check
ALL
services requested.
Reason for Visit
Pre-Employment
Return to Duty
Post-Accident
Follow-Up
Reasonable Suspicion
Random
Other
Workers' Compensation
Injury Evaluation & Treatment Including Blood Borne Pathogen
Type of Test
Urine Drug Test
Observed Drug Test
DOT (Send Out)
NON-DOT (Send Out)
Aspirus Provided CCF
Company Supplied CCF (Collection Only)
Pre-Employment Screenings
Communicable Disease
Respirator Physical
DOT Physical
TB Skin Test
Firefighter Physical
Ishihara 12 Plate Color Vision
Hazmat Physcial
Near Vision
Pre-Employment Physical with Snellen Vision
Fly Stereo-Depth Perception
Pre-Placement Screen-Therapy
Pulmonary Function Test (PFT)
Other
If Non-DOT, select option below:
5 Panel
10 Panel
Onsite Rapid Testing
4 Panel
5 Panel
9 Panel
10 Panel
12 Panel
DOT
Breath Alcohol Test
Non-DOT
Other
Vaccinations
Hep A
Tetanus
Hep B
Varicella
MMR
Flu Vaccine
TDAP
Other
Labs
Hep A Titer
Varicella Titer
Hep B Titer
Quant Gold
MMR Titer
Lead Blood Draw
TDAP Titer
Zinc Protoporphyrin ZPP
Other
Annual Screenings
DOT Recertification
Annual Physical Exam
HazMat Physical
Respirator Questionnaire
Respirator Physical
Audiogram
Respirator Fit Testing
Other
Print
Submit
Should be Empty: