Department of Workers Compensation

New partners of Temecula 24 Hour Urgent care, please fill out the form below. Please include as much information as possible. Once the form is complete, just submit it using the button below. One of our representatives will contact you shortly.

NOTE: This form is for employers contracting with Temecula 24 Hour Urgent Care only, not for individual patients.

EMPLOYER PROFILE:
Company Name:
Contact(s):
Address (Include Street, City, State,Zip):
Phone:
Fax:
Billing Address:
Billing Contact:
Email Address:
Phone:
Fax:
Authorized Representative:
Please check all items and procedures that you require for your employee: Worker's Compensation
Always call for prior authorization
No prior authorization required
Post Accident/Injury Drug Screen Always Required
Post Accident/Injury Drug Screen As Requested
Modified Duties Available
No Modified Duties Available Employment Exams
Hair Follicle Collection
Non-DOT Breath Alcohol Test
DOT Breath Alcohol Test
TB/PPD Skin Test
Spirometry/PFT
Chest X-Ray
Hepatitis B Series
Audiogram
Basic Physical Exam
DMV/DOT Physical Exam
Range of Motion / Back Exam
Back X-Ray
EKG
Rapid S-Panel Drug Screen
Non-DOT Drug Screen
DOT Drug Screen
Report Results To: By checking this box you are assumed to be electronically signing this document, signifying that you are the authorized representative for the applicant company, and that you have the authority to submit this application and interact with Temecula 24 Hour Urgent Care on your company's behalf.