Employer Profile Form COMPANY INFORMATION Name of Person Completing This Online Form: Business Name: Address: City: State: Zip Code: Mailing Address: Same as above City: State: Zip Code: Industry Type: Date: W/C Contact: Title: Phone: Fax: Email: Employee Qty: List the types of injuries that could occur at your facility: W/C Carrier: Billing Address: Same as above City: State: Zip Code: Adjustor: Phone: Fax: Email: YOUR COMPANY'S PREFERENCES Desired course of treatment, dependant on injury (i.e. conservative, aggressive, MRI last resort, etc.): Subspecialists on your Panel you would prefer us to use, if needed: Spine: Neurologist: Other: Imaging: Work Status Guidelines you would like the provider to address at each visit: CAN YOU PROVIDE THE FOLLOWING TYPE OF WORK FOR INJURED WORKERS? Sedentary: Light: Medium: Heavy: *Do you have printed guidelines for us to review? YesNo *Is there an established Return to Work Program? YesNo *Would you like an onsite provider tour and assessment? YesNo *Would you like to directly contract with BJISG for your imaging needs? YesNo Additional Requests (i.e. Company forms, Early Return to Work Program, etc. ):
