Customer Service Agreement
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1 Customer Service Agreement Doctors Care Employer Health Services 1818 Henderson Street Columbia, SC : : sales@doctorscare.com SECTION I: Today s Date COMPANY INFORMATION TPA Name Company Name Number of Employees Health Insurance Carrier Main Company COMPANY INFORMATION 1. Primary Contact/DER Name 2. Secondary Contact Title/Role Title/Role Primary Billing* Billing BILLING INFORMATION Contact Name and Title Workers Comp Billing Invoices (Secure) Carrier Name Billing Are workers comp claims to be billed to carrier or to your company? *Provide alternate billing addresses on page 3 Bill Carrier Bill Primary Billing Page 1 of 5
2 SECTION II: REQUIRED SERVICES AND REPORTING Hair 5 Panel Drug Screen, non-dot (80300.H) Hair Collection Only (99000.H) 5 Panel In-house Drug Screen non-dot ( I) 10 Panel In-house Drug Screen non-dot ( I) 5 Panel External Lab DOT Drug Screen (80300.D) 5 Panel External Lab Drug Screen, non-dot ( L) 10 Panel External Lab Drug Screen, non-dot ( L) Urine Collection Only, DOT (99000.D) Urine Collection Only, non-dot (99000.N) Breath Alcohol Test DOT (82075.D) Breath Alcohol Test non-dot (82075.N) DOT Physical (99385.D) General Physical (99385.G) Pre-Employment Physical (99385.P) Other: Respiratory Clearance Physical (99385.R) History Review W/O Exam (99385.P0010) Fit for Duty Physical (99385.F) Hazmat Physical (99385.H) EKG (93000) Pure Tone Audiometry (92552) OSHA Audio Exam (92552.O) Visual Acuity Test (99173) Color Vision Exam (92283) Hep A Vaccine (90632) Spirometry/Breathing Capacity Test (94010) Chest X-ray 1 View (71010) Chest X-ray 2 View (71020) Flu Vaccine (90658) Blood Lead Level (83655) Hep B Vaccine (90746) Hepatitus B Titer (86706) Tetanus,Diptheria (90714) Tetanus, (Tdap) (90715) PPD (TB Test) (86580) PPD/TB Q Gold/Blood (86480.PPD) MMR Vaccine (90707) Varicella-Zoster (86787) Rubella Antibody (86762) Mumps Antibody (86735) Rubeola Antibody (86765) Respirator Fit Test (99078.R) Respirator Questionnaire (99078.Q) WELLNESS SERVICES Biometric Screening ONSITE TRAINING SERVICES Heart Healthy Nutrition Stress Relief Diabetes Tobacco Cessation Weight Control Back Care Sleep Disorders Men and Women s Health Bloodborne OSHA Training Services *EMPLOYEE MUST BRING IN COMPLETED AUTHORIZATION FORM FOR SERVICES TO BE PERFORMED WORKERS COMPENSATION Indicate where the Return to Work Status report is to be sent: Workers Compensation Injury Treatment Post-Accident Drug Screen Required DOT Non-DOT (5, 7, 9, or 10 Panel) Please indicate where and how breath alcohol tests and physical results are to be reported: Return with Employee Mail Please list specific protocol instructions* *Doctors Care will report results and applicable information as specified above Page 2 of 5
3 SECTION III: OPTION A: OPTION B: Recurring Payment (requires credit card) BILLING AND PAYMENT INFORMATION Pay via Visa, MasterCard, Discover Card or American Express with receipt ed to the billing contact on file. Invoices are mailed on the 2nd business day of the month and are due on the 20th. Payments for accounts with a credit card on file will be processed after the 20th of each month. Any billing discrepancies must be brought to our attention prior to the 20th so we may make the necessary corrections before processing your credit card payment. Past due accounts will be assessed a late payment fee of 15%. Accounts with past due balances over 60 days old will be terminated and referred to a collection agency for payment. Balance Billing (requires approval and credit card* for balance billing) A monthly invoice of open charges will be sent to you at the billing address on file. Customer agrees to pay the invoice on the 20th of each month. If payment falls more than 60 days in arrears, your account will be inactivated and referred to a collection agency for payment and services must be paid for at the time they are rendered. Past due balances will incur a late payment fee of 15% of the outstanding balance. *Credit card will not be billed unless payment is not made within 30 days. I,, authorize Doctors Care (c/o UCI Medical Affiliates) to charge my account for balance due for payment of my account with Doctors Care. Type of Card CREDIT CARD INFORMATION Visa MasterCard Discover American Express Cardholder Name* Account Number Expiration Date Billing Zip Code *The name MUST match the name on the credit card listed I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify UCI Medical Affiliates in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. Credit Card Authorization Signature: All accounts may pay online by echeck by visiting If you have some services that must be billed to an alternate billing address, please provide that information below: Name Services to be billed to this address Please list the Doctors Care facility/facilities that your company would like to use: Page 3 of 5
4 SECTION IV: FEES & NOTES This section to be completed by business development representative Page 4 of 5
5 SECTION V: CUSTOMER ACKNOWLEDGEMENT Employer Authorized Name Title X Employer Authorized Signature Date This agreement will be in effect until either party gives written notice of change of service, terms or termination. Page 5 of 5
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