RiteCare

The Rite Care For Your Employees

Client Information

Company Name*

Authorized Contact

Contact Telephone

Fax:

Address

Worker's Comp Insurance

Insurance

Address

Phone Numer

Fax

Contact

Billing Information

Billing Address

Billing Cycle*

Invoice *Please note a separate Credit Card authorization form is required

Drug Screen

Does your company require a mandatory drug-screen after any work-related injury?

If so, which one?

Special Requests

Reports

Preferred method of receiving confidential patient information results*

Would you like a weekly or monthly status report for patients?

If so, what is your preferred method of receiving the summary?

Special Requests

Additional Information

Preferred Lab

Special Requests

Location

Select Location*

1250 S. Miami Ave,
Miami, FL 33130

14201 S. Dixie Highway,
Miami, FL 33176

915 West 49 Street,
Hialeah, FL 33012

3399 NW 72nd Ave.
Miami, FL 33122