HINESVILLE SAVANNAH POOLER. STATESBORO Hill Pond Ln BLUFFTON. Walk-in Hours for Urgent Care & Occupational Health Services

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4 Eisenhower Drive POOLER Walk-in Hours for Urgent Care & Occupational Health Services Monday - Friday 9:00 am - 8:00 pm Saturday 9:00 am - 5:00 pm Sunday 12:00 pm - 5:00 pm For more information, call the clinic or For medical emergencies, call 911. Pooler Parkway Canal Street Park Ave. Canal Street Pipemakers Circle Publix HINESVILLE SAVANNAH 84 Hodgson Memorial Dr. Commercial Ct. Commercial Dr. General Stewart Way Commercial Dr. *This location also offers appointments for Work Care patients. Olvey Rd E. Oglethorpe Hwy Call for details. 361 Commercial Drive Savannah, GA Phone: Fax: Patriot Trail 107 Canal Street Pooler, GA Phone: Fax: East Oglethorpe Hwy Hinesville GA Phone: Fax: BLUFFTON Carecore Dr. Progressive Street Buckwalter Pl Blvd Buckwalter Place Shopping Center Buckwalter Parkway STATESBORO Hill Pond Ln Bermuda Run Rd Brampton Ave 67 Fair Rd East Georgia Regional Hospital Hawthorne Rd 67 Fair Rd Bluffton Parkway Veterans Memorial Pkwy 3 Progressive Street Bluffton, SC Phone: Fax: Bermuda Run Road Statesboro, GA Phone: Fax:

5 We take the {WORRY} out of WORKERS COMPENSATION. Will this be reportable? What if the doctor says my employee needs time off of work? Does the doctor understand the nature of our business? The primary goal of the Treating Physicians at Your Immediate Care Centers is the return of injured employees to productive employment as efficiently and as safely as possible. Reduced Costs Cases seen in our urgent care setting typically cost at least 50 percent less than those directed to a hospital emergency room. In addition, we manage your employees care according to standards that minimize unnecessary costs. High Standard of Care Each of our centers always has an experienced physician on duty. Return to Work - At each of our centers, our treating physicians follow a standardized Workers Compensation Patient Care & Return to Work Guidelines. Responsive Service Our professional center managers and staff are experienced in Workers Compensation case management and are instrumental in facilitating all aspects of your employees care and return to work plan. Commitment to Communication Treating physicians notes, Return to Work forms and reports are communicated to the employer in a timely manner -- let us know how you want to be contacted. Stay in control. Your healthcare costs. Your employees. Your business.

6 Armstrong Atlantic University Atlanta Gas Light Averitt Express Baldino s Belfair Property Owners Association Bridge Terminal Transport Bulloch County California Cartage CareCore National Ceres Marine Terminal Chatham Area Transit Chatham County Chatham County Sheriff Chatham Steel City of Bloomingdale City of Garden City City of Hinesville City of Pooler City of Savannah City of Statesboro Coca Cola Colonial Oil Critz, Inc. Dan Vaden Automotive Group Daniel Defense Derst Baking Company Dorsey Tire EMC Engineering Fed Ex Freightliner Fuji Vegetable Oil Georgia National Guard Georgia Ports Authority Georgia Southern University Goodwill of the Coastal Empire Gulfstream Hinesville Ford Horizon Staffing Hospice Savannah ILA Local 1414 J.C. Lewis Liberty County Liberty County Sheriff Mitsubishi Ports America Savannah Bank Savannah Technical College Savannah Tire Schneider Logstics Snelling Staffing Southeastern Freight Lines Southside Fire SSA Cooper St. Joseph s/candler Health System Sun City Hilton Head The Landings Club Thunderbolt Marine Town of Bluffton UPS Wal-Mart Distribution Yancey Brothers Yellow Freight

7 OCCUPATIONAL MEDICINE QUESTIONNAIRE Employers, please complete this for our records so that we will have your information on file. COMPANY NAME PHYSICAL ADDRESS MAILING ADDRESS CORPORATE MAILING ADDRESS (IF DIFFERENT FROM ABOVE) WEBSITE PRIMARY CONTACT NAME TITLE MAILING ADDRESS PHONE OCCUPATIONAL MEDICINE SERVICES (CIRCLE) Physicals DOT Physicals Audiograms Chest X-Rays PFT Drug Screens Type(s) Drug Screen Collection Only OTHER: OCC MED CONTACT NAME TITLE MAILING ADDRESS PHONE OCC MED BILLING ADDRESS: NOTES (indicate if Occ Med services currently provided by another provider)

8 WORKERS COMENSATION SERVICES Is St. Joseph s/candler Immediate Care (any location) or South Georgia Immediate Care (any location) currently listed on your Workers Compensation Panel of Physicians? YES LOCATION(S): NO NOT SURE WORKERS COMENSATION INSURANCE CARRIER (Company Name and Billing Address) WORKERS COMPENSATION CONTACT NAME TITLE MAILING ADDRESS PHONE OCC MED BILLING ADDRESS: NOTES NOTES: Date Entered Salesforce.com:

9 EMPLOYER S AUTHORIZATION FOR EXAMINATION and/or TREATMENT Employer must complete this form prior to the employee visit. Employee must present photo ID at time of service. Employer Company Name Patient Name Patient SSN/ID# Employer Physical Address Employer Billing Address Contact Name Contact Work Phone Contact Contact Title Contact Mobile Phone Contact Fax Best Form of Contact Work Phone Mobile Phone Fax Other: Authorization Signature Visit Date BILLING INFORMATION Bill EMPLOYER (see Employer Billing Address above) EMPLOYEE to pay at time of Service Bill WORKERS COMPENSATION Insurance Company / TPA*: Ins. Co. Policy # Phone Contact Claim # WORK-RELATED INJURY CARE Date of Injury: Evaluate and Treat Light Duty is Available Be sure to indicate Drug Screen and/or Breath Alcohol Test required under Are Drug Screens and/or Breath Alcohol Tests covered by Workers Comp Ins Co/TPA? Y N N/A REPORTING RESULTS Fax paperwork to employer paperwork to employer Call employer Give all paperwork to employee Dive DOT card/instant Screen Results Card only SPECIAL INSTRUCTIONS DRUG and ALCOHOL TESTING SERVICES REASON FOR TESTING: Post-Accident Random Pre-employment Reasonable Suspicion DOT New Certification DOT Recertification TEST REQUIRED: DOT Drug Screen Instant 5-Panel Urine Screen Instant 10-Panel Urine Screen Hair Follicle Testing Non-DOT Specimen Collection only Breath Alcohol Test OCCUPATIONAL MEDICAL SERVICES DOT Physical New Certification DOT Physical Recertification Non-DOT Physical (Standard) Non-DOT Physical (Employer Provided) Fit For Duty Evalutaion (Physical + PPE) Job Title/Desc Audiogram Pulmonary Function Test (PFT) Chest X-Ray Lumbar Spine X-Ray EKG TB Test Nicotine Test Flu Shot Hepatitis Vaccine (circle) A B Both Other

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