Customer Credit Application Application Form 1Business Details2Billing Details3Credit Details4Invoicing Details5Service Details6Contact Details7Sign & Submit Business Name* Doing Business As (DBA) Street Address* City* State* Zip* Telephone*FaxPlease list all offices and/or affiliate addresses. Billing AddressBilling Address* City* State* Zip* Accounts PayableAccounts Payable Contact Name* Accounts Payable Contact Phone*Accounts Payable Contact Email* Federal Tax ID Number* Other DetailsType of Business* Year Business Established* Years in Business* How Long at Present Location* Credit RequestCredit Limit Requested* Credit Terms Requested*- Select -Credit CardNet 30Other (Please describe.)Other Credit Terms Requested* Credit ReferencesRequired for credit amounts over $1000.00Reference 1Company Name Mailing AddressTelephoneFaxContact Name Contact Title Contact Email How long have you been doing business with this company? Reference 2Company Name Mailing AddressTelephoneFaxContact Name Contact Title Contact Email How long have you been doing business with this company? Reference 3Company Name Mailing AddressTelephoneFaxContact Name Contact Title Contact Email How long have you been doing business with this company? Does your company handle invoice payments via EFT?*- Select -YesNoDoes your company require invoices to reference a PO or job site?*- Select -YesNoIf yes, enter Blanket PO.*Notice: If your company has multiple PO / job sites or pays via EFT, please contact Frank Stoltz to provide all required information — via phone at 337-445-1015 or via email at fstoltz@epsphoenix.com. Do you have a drug or alcohol program?*- Select -YesNoRelated ServicesWill you be using our laboratory?*- Select -YesNoYour Laboratory Name* Your Laboratory Account Number* Will employees bring COC's, or will we keep COC's at the clinic?*Please note, you must order them through lab or MRO and have them delivered to the location you choose to use.- Select -Employees will bring COC'sKeep COC's at clincWill you be using our MRO (Medical Review Office)?*- Select -YesNoYour MRO Name* Your MRO Address*Your MRO Phone*Your MRO FaxYour MRO Email* What type of drug screens do you require?Check all that apply. Instant Test DOT Non-DOT Panel Other (Please describe.) Other Required Drug Screens* Who can receive results?Primary Contact(s)*Secondary Contact(s)*Who can authorize treatment?Authorizer(s)*Safety & Supervisors* Authorization for Release of Information* I hereby warrant that the above information is true and correct and is furnished to establish a business relationship with EPS Phoenix Medical Solutions, LLC. I hereby agree that EPS Phoenix Medical Solutions, LLC, may investigate my record and that, if approved, EPS Phoenix Medical Solutions, LLC, may furnish this authorization to secure the information they need to establish a business relationship. Late Fee Notice* I understand that late fees will be assessed to all past due invoices, 2% or $20 per month (whichever is greater). I further understand that nonpayment (or invoices reaching 90 days past due) will result in all services by EPS Phoenix Medical Solutions, LLC, being suspended for employees of your company until your account is paid in full. Insurance Disclaimer* I understand that EPS Phoenix Medical Solutions, LLC, will bill for services rendered, and I agree to pay such billing within thirty (30) days of the mailing of such billing for the services provided. I understand the employer is responsible for payment of such billing. I understand that EPS Phoenix Medical Solutions, LLC, DOES NOT bill Medicare, Medicaid, worker’s compensation or private insurance. My Name* My Email* My Signature*NameThis field is for validation purposes and should be left unchanged.
