Company Setup Form

Sanford OccMed Company Setup Form 

Company Setup Form

Thank you for choosing Sanford Health Occupational Medicine Clinic. 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.

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.

General Information
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Desired Clinic Location








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Company Information
Please select one

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Please Check Which Results Contacts are Authorized to Receive



Please Check Which Results Contacts are Authorized to Receive



Please Check Which Results Contacts are Authorized to Receive



How did you hear about Sanford Health Occupational Medicine Clinic?



Billing/Third-Party Information
Billing/Work-Related Injury Insurance
North Dakota Worker's Comp. Insurance

Services
Drug Screen/Breath Alcohol Non-DOT


Drug Screen/Breath Alcohol DOT


Physicals


Screenings



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

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

 
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