Employer and Adjuster Portal
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Clinic Forms

Click on a link below to access useful tools for you and your employees:

Employer Authorization Form

Map & Directions

In Case of Injury (ENGLISH)

In Case of Injury (SPANISH)

Business Documents

Click on a link below to access necessary business documents:

Tax ID Change Notification – Effective January 1, 2018

Clinic Locations and Billing/Remittance Address

W9 – 2018 (Effective for Dates of Service on, or after, January 1, 2018)

W9 – 2017

OSHA Respirator Surveillance Forms

Click on a link below to access the appropriate questionnaire based on the type of mask being worn:

OSHA Respirator Questionnaire for Non-Full-Face and Non-SCBA Respirators (English)

OSHA Respirator Questionnaire for Non-Full-Face and Non-SCBA Respirators (Spanish)

OSHA Respirator Questionnaire for Full-Face and SCBA Respirators (English)

OSHA Respirator Questionnaire for Full-Face and SCBA Respirators (Spanish)