Employer Profile Form

    COMPANY INFORMATION







    YOUR COMPANY'S PREFERENCES

    Subspecialists on your Panel you would prefer us to use, if needed:

    CAN YOU PROVIDE THE FOLLOWING TYPE OF WORK FOR INJURED WORKERS?

    *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