National Account Overland Park
Resume:
*AI********NA*
AI********NA
Instructions for Service Provider
Please proceed to the following location:
HealthWorks Medical LLC
Ste A8
Bowling Green, KY 42101
Providers with eScreen123 must scan ePassport into eScreen123. Use eScreen Scheduled Event Account. Scan this barcode into eScreen123®
Instructions for Christopher Hodge
Participant ID:
Account: 132***-****
BOWLING GREEN METALFORMING L.L.C.
This order must be completed by:
8/21/2023 10:59 PM (CT)
https://www.escreengo.
com/HealthHistory
Account Type: National Account
Phone:
© 2019 Abbott. All rights reserved. All trademarks referenced are trademarks of either the Abbott group of companies or their respective owners.
Note: Completion time displayed does not mean that the service provider is open until the time shown. Note: Please call service provider for operational hours and to schedule an appointment or visit the service provider’s website for hours of operation. Bill services to: eScreen, Inc., PO Box 25902,
Overland Park, KS 66225
• You are required to take a photo ID,
this ePassport, and all documents with
which it printed.
• If you are under 18, a parent or legal
guardian may be required in order for
services to be performed. Verify with
the service provider before arriving.
• DON'T FORGET to complete your
health history online form before you
Fax: 364-***-**** arrive for your physical by visiting Services(1):
Regulation: NON-DOT
Reason for Test: Pre-employment
Reason for Service: Pre-employment
Services(1):
1. Urine Collection - 1734 -
10DSP/BRB,BNZ200/PHN (1734)
1. Non-DOT Physical
Clinic #: 56287 eScreen Account #: 132***-**** Confirmation #: AI80966229NA
[ ] Non-DOT Physical - The NonDOT exam is now electronic in ePhysical. If you are unable to perform the service electronically follow the instructions below to prevent delays for this event: Use passport forms for the exam Confirm all sections of the form are complete, including: • Applicant’s name/Demographic information • Height • Weight • Pulse • Blood pressure • Vision (visual acuity/color/Monovision/Horizontal field of Vision) • U/A Dip • Provider signature at the bottom • Hearing (whisper test) • Physical Examination Clinic Instructions:
Please follow standard protocol unless specified for the services listed below. Applicant/Employee Name:
Confirmation Number:
eScreen Account Info:
eScreen Site ID:
Hodge, Christopher
AI80966229NA
56287 - HealthWorks Medical LLC
Please Note: The information on this document is specific to a single event. To ensure timely and accurate reimbursement for the services, please use this information only for the applicant referenced above. AI80966229NA
AI80966229NA
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123 software.
This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed. Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the eScreen123 Follow-Up tab or fax completed documents to 913-***-****. Please fax ORIGINAL FORMS ONLY. Copies/carbons/scanned images/highlights are often illegible upon receipt. Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly. Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the instructions.
If any occupational health service(s) are requested in addition to the services listed, please call 1-800-***-****, option 5 for approval/direction.
Clinic Instructions Page 1 Of 2
Clinic Instructions:
Please follow standard protocol unless specified for the services listed below. Applicant/Employee Name:
Confirmation Number:
eScreen Account Info:
eScreen Site ID:
Hodge, Christopher
AI80966229NA
56287 - HealthWorks Medical LLC
Please Note: The information on this document is specific to a single event. To ensure timely and accurate reimbursement for the services, please use this information only for the applicant referenced above. AI80966229NA
AI80966229NA
If your location is installed with the eScreen123 system, please be sure to check this event into the eScreen123 software.
This ePassport is your clinic's authorization to perform the Health-eScreen occupational health service(s) listed. Services completed in eScreen123 are already in our system and don’t require faxing or uploading of documents. For paper/handwritten forms completed outside of eScreen123, please upload completed documents to the donor's event in the eScreen123 Follow-Up tab or fax completed documents to 913-***-****. Please fax ORIGINAL FORMS ONLY. Copies/carbons/scanned images/highlights are often illegible upon receipt. Your clinic will be reimbursed for the requested services performed. If your clinic is contracted for the services, you will be reimbursed at your contracted rate. If you are not contracted, please invoice eScreen directly. Please refer to the component checklist provided below to ensure all occupational health service(s) are completed per the instructions.
If any occupational health service(s) are requested in addition to the services listed, please call 1-800-***-****, option 5 for approval/direction.
BILLING INFORMATION:
Invoices for services must include the eScreen account information and SSN/ID or confirmation number (as listed above) for the patient. Direct all invoices to eScreen at: eScreen, Inc.
Attn: Accounts Payable
PO Box 25902
Overland Park, KS 66225-5902
Incomplete medical service forms will not be reported, and the reimbursement will not be issued until all required information has been received by eScreen. If you have any questions, please contact eScreen at 1-800-***-****, option 5 Clinic Instructions Page 2 Of 2
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