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MD MEDICAL CLINICS

OCCUPATIONAL SERVICES
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MD Medical Clinics
1300 N Kraemer Blvd
Anaheim, CA 92806
714-630-6363
714-630-6318fax
 
 
 
 








 
 

 

 

For Immediate setup go to the

EMPLOYER INFORMATION PROFILE TAB 

You may print & fill-out.  Please then fax or bring to clinic with you. 

You may also copy and paste on to the above message box and email for prompt setup.

 

 

 

MD MEDICAL CLINICS

Occupational-Industrial Medical Services

 RICHARD E. HUGHES M.D. ~ Medical Director-Board Certified

 1300 N Kraemer Blvd, Anaheim, CA 92806    

                                     714-630-6363 Fax 714-630-6363   www.mdmedicalclinics.com                                                                                            

              No Appointment Necessary / Minimal waiting                                 

 

 

                         EMPLOYER INFORMATION PROFILE                      

 

   DATE: _______________________________

 

EMPLOYER: _____________________________________________________________________________

 

ADDRESS: _______________________________________________________________________________

 

CITY, STATE, ZIP: ________________________________________________________________________

 

TELEPHONE#: (    )___________________________ FAX # (     )____________________________________

 

COMPANY CONTACTS: ____________________________________EMAIL:_________________________

 

MAILING ADDRESS (OR P.O. BOX)__________________________________________________________

 

CORPORATE OFFICE ADDRESS:____________________________________________________________

 

CITY, STATE, ZIP: ________________________________________________________________________

 

TELEPHONE #: (       ) __________________ CONTACT (S)_______________________________________

 

NUMBER OF EMPLOYEES: _________________  SHIFTS/HOURS ________________________________

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 Note: This information is put into our computers in advance, in case there is an injury you will be set-up for

 the front desk to assist you promptly. ~THERE IS NO CHARGE OR CONTRACT FOR THIS.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

WORKERS’ COMP INSURANCE: _________________________________________________________________________________

 

ADDRESS: _________________________________________________________________Agent:______________________

 

CITY, STATE, ZIP: ____________________________________________________________________________________________

 

TELE#: (    ) _____________________________ POLICY # ________________________ EXP: ___________________

 

CLAIM#_______________________________________

******************************************************************************************************

 

PLEASE CHECK QUESTIONS BELOW FOR SETUP!

DO DRUG SCREEN WITH INJURIES? (Post -accident drug test)  __YES  NO__ SEND SAP____

 

CALL COMPANY FOR BILLING INSTRUCTIONS?     YES     NO (First Aid or W/C Ins)

 

LIMITED DUTY AVAILABLE? (Modified work)    YES  NO  CALL ON EACH INJURY

 

RECHECK APPTS BEFORE OR AFTER WORK?     YES  No  ANYTIME

 

POST OFFER/ PRE-PLACEMENT PHYSICALS  YES  NO  Prior customized testing

 

Special Requests:___________________________________________________________________

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~                    

 

MAIL – OR – FAX BACK 714-630-6318 or email: mdmed@pacbell.net

                   

                                  Mon-Friday 7:30 AM - 6 PM      

                                                          Closed Saturday & Sunday                             

 

"KEEPING YOU, ON YOUR JOB, IS OUR JOB"