Healthcare Employer Application

Healthcare Employer Application

Purpose: This application establishes the employer as a contracting client for occupational, employee health, or population health services offered by the provider organization. Completion and submission of this form constitutes the employer's formal request to enroll and acknowledges the employer's authorization for the provider to evaluate eligibility, collect required documentation, and initiate onboarding activities.

1. Employer Identifying Information

2. Primary Contact for Onboarding

Contact Name:   Title:

3. Entity Type and Legal Status

Select applicable entity type(s):
Corporation   Limited Liability Company (LLC)   Partnership   Sole Proprietor   Nonprofit / Government

4. Insurance and Worker Classification

5. Services Requested

Indicate services requested (check all that apply):
Employee Health Clinic / On-site Clinic
Occupational Health Services (physicals, fit testing)
Vaccination Clinics (flu, COVID-19, etc.)
Pre-employment Screening & Background Health Checks
Drug & Alcohol Testing
Temporary / Contract Clinical Staffing
Workers' Compensation Case Management

6. Employee Population and Enrollment

7. Onboarding Documents and Attachments

The employer must provide copies of the following documents as part of onboarding. Check boxes to indicate documents included with this application:

EIN verification or tax document
Certificate of Insurance (COI)
Completed W-9
Employee census / enrollment list
Signed authorizations for release of medical information (as required)

8. Privacy, HIPAA Acknowledgment and Authorization

By submitting this application, the employer acknowledges and agrees that the provider will maintain protected health information (PHI) in accordance with applicable privacy and security laws. The employer certifies that it has the authority to request services and, where necessary, will obtain written employee authorizations for the release of individual employee health information to the employer or its designees. The employer further acknowledges that any use of PHI will comply with minimum necessary and purpose-limited principles.

HIPAA Notice Acknowledgment: I acknowledge receipt of the provider's Notice of Privacy Practices and understand my obligations regarding employee authorizations.

Authorization Expiration Date:   If left blank, authorizations will be valid for one year from the effective date of services except where otherwise required by law.

9. Financial Terms & Billing

Billing Contact Name:   Phone:

Standard payment terms are net 30 days from invoice date unless an alternative payment arrangement is executed in writing. Employer agrees to pay undisputed invoiced charges in accordance with the provider's published fee schedule or contracted rates.

10. Attestation, Authority to Bind, and Certification

The undersigned represents and warrants that they are an authorized representative of the employer named in this application and have the full power and authority to enter into agreements on behalf of the employer. The undersigned certifies that the information provided in this application and any attachments is true, complete, and accurate to the best of their knowledge. The employer agrees to indemnify and hold harmless the provider from third-party claims arising from false statements, omissions, or the employer's failure to obtain required employee authorizations.

The provider reserves the right to suspend or terminate services if required documentation (including proof of insurance, W-9, or employee authorizations) is not received within a reasonable period following acceptance of this application. Acceptance of the application by the provider is contingent on successful completion of credentialing, insurance verification, and compliance review.

11. Additional Comments

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