Use this form if you need to:

Submit a request for agreements (generally for workers’ compensation clients) when the current provider can’t meet the access requirements.

Submitter Name (Required):
Submitter Email (Required):
Type of Request (Required):Subcontractor Agreements
Employer Name:
Financial Class:Auto & Liability Government Health Insurance IPA Lien Medicaid Medicare Medicare Replacement Other Self Pay Work Comp
# of SCAs in the Past 12 Months:–None–Less than 3 3 or More
Services (Required):Alcohol Testing (saliva) Computer Workstation Ergonomics Assessment Drug Testing (specify DOT/Non-DOT and 5/10 panel in comments) E-Learning Series Essentials Functions Test (one-time) Fit for Duty Functional Capacity Evaluation (97750) Industrial Ergonomic Risk Analysis Job Analysis Medical Review Office Fee (non-negative drug test result) Nearsite Injury Prevention and First Aid Onsite Industrial Wellness Specialist Onsite Program Development Other Physical Therapy Services/Occupational Therapy Services POET – Agility + MSK POET – Agility + MSK + UQ-CT POET – Agility Only POET Development Prevention Injury Software Prevention Program Development Work Conditioning (97546) Work Conditioning Evaluation (97545) Workforce Injury Prevention Training ( 1-3 hours)
Description (Required):
Clinic Name:
Clinic Address:
Clinic City:
Clinic State (Required):–None–National AZ AR DE DC GA IL IN IA KS KY MD MI MS MO NE NC OH OK PA SC SD TX VA WV WI
Clinic Zip Code:
Client/Payor Contact Name (Required):
Client/Payor Contact Phone Number:
Client/Payor Contact Email:
Attachment from the client/payor?:–None–Yes No
Original email from the client/payor?:–None–Yes No