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Sanford Health Occupational Medicine Clinic:

Company setup form


Thank you for choosing Sanford Health Occupational Medicine Clinic. With locations in Bismarck, Dickinson and Minot, ND, dedicated to industrial medicine, the Sanford Health Occupational Medicine Clinic thanks you for choosing us and is confident we can meet your company's needs.

In order to use our clinics, you must establish an account with us prior to scheduling of services. By doing so, we will have access to your company's specific information and protocols allowing accurate and timely service to your company.

To set up an account with Sanford Health Occupational Medicine Clinic, follow the instructions listed here:

  • Fill out the new company setup form below
  • Allow one business day for us to complete the setup of your account. You will be contacted by an account representative to verify protocol information.
  • If you have any questions, contact the clinic at 701-323-8170

The staff and providers at Sanford Health Occupational Medicine Clinic look forward to working with you.

Clinic billing and practices guidelines:

  • All invoices require payment within 30 days of receipt
  • The Sanford Health Occupational Medicine Clinic reserves the right to withhold results due to nonpayment and to require a credit card on file prior to services if we deem it necessary
  • If any work-related injury claims are denied by the designated workers compensation insurance, it is the patient's responsibility to pay the invoice
  • The clinics will report results of physicals and work-related injuries as well as provide employee copies of chains of custody within one business day
  • The clinics accept walk-in appointments for work-related injuries and drug testing; for all other services please call for appointment

CompanyName:
Local physical address:
City:      State:     Zip:
Company contact
Title:
Phone:      Fax:
E-mail:
Company type:
Number of employees:
Clinic location to be used:  

Billing/third-party information:

Check this box if the billing address is the same as above

Name of third-party administrator/company:
Address:
City:      State:      Zip:
Phone:      Fax:
MRO fax number:

Billing/work-related injury insurance:

North Dakota Worker's Comp. Insurance:
If no, your Worker's Comp. Insurance:

Services

The company contact will be called for service request specifics.

Drug screen/breath alcohol

Physicals/screenings
Non-DOT
Pre-placement
Random
Reasonabl suspicion
Post-accident
Return-to-duty
Breath alcohol		 Physical
DOT/CDL exam
Respiratory clearance exam
Annual wellness exam
Return-to-work exam
Asbestos physical
Dot
Pre-placement
Random
Reasonable suspicion
Post-accident
Return-to-duty
Breath alcohol		 Screening
Audio
Vision
Fit-for-duty (lift, push, pull, test)
OSHA questionnaire
Respirator fit test
Lab tests
Immunization
X-ray

Do you have paperwork that you'd like to use specific to your company?

Would you like us to be your designated medical provider for injuries:

Company resulting information

Please check one:
Send results to all contacts listed below.
Send results in the order below as contacts are available.

Please check which results contacts are authorized to receive

1. Company contact:   
Phone:     Email:      Fax:
Drug/breath alcohol results Report injury Physical results Other

2. Company contact:   
Phone:     Email:      Fax:
Drug/breath alcohol results Report injury  Physical results Other

3. Company contact:      
Phone:     Email:      Fax:
Drug/breath alcohol results Report injury Physical results Other

If you have multiple locations you'd like to attach to this account, please include a list of all your locations here:

How did you hear about Sanford Health Occupational Medicine Clinic?

Online
Employee recommedation
Company referral
Magazine
Newspaper
Community event
Drive by
Other:

  
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