Profile Form

Employer Profile Form

Company Name

Name

Email

Phone

Street Address

Street Address 2

City

State

Zip Code

Georgia Spine Orthopaedics & Neurology Offices to be Used

Type of Business

Number of Employees

Job Description

Return to Work Policy

When Do You Review or Update Your Posted Panel of Physicians

Insurance Information (Please Select One)

Insured Self Insured Self Administered

Insurer Name

Insurer Contact

Insurer Email

Insurer Phone

Insurer Fax

Insurer Address

Insurer Address 2

City

State

Zip Code

Bill To (Select One)

Employer Insurer/TPA

Work Status Report (Select all that apply)

Employer Insurer/TPA

Most Common Injuries

Other Physicians on Panel

Can We Use GSON Locations for (Select if Applicable)

Physical Therapy Imaging (MRI) N/A

Notes