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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