Coordinated Health

Company Registration Form

  • If you prefer to print and fax the company registration form, click here. Register your company to receive our Employer Health Services and access to 24/7 healthcare for your employees. Items in RED are required. We are an e-screen collection site.
  • Company Information

  • Please provide an estimate of how many employees work for your company.
  • Employer Health Services Billing Information Primary

  • Please specify if certain employer health services should be billed to different addresses. Example: Drug Screens are billed to a 3rd party and physicals are billed to the employer.
  • Secondary

  • Please specify if certain employer health services should be billed to different addresses. Example: Drug Screens are billed to a 3rd party and physicals are billed to the employer.
  • Third Party Administrator Information

  • Workers' Compensation Insurance Information