Acton 978-637-2320

Canton 339-502-9889

Text size

Patient portal

Reserve my spot

Workers’ comp insurance form

Give us your workers’ compensation insurance details once and we keep them on file, so an injured employee only needs photo ID and the date of injury. Please update us when your policy renews.

This form is for business and insurance details only. Please do not include employee names, dates of birth or injury details. Not set up yet? Fill in the employer account form too.

Company
Workers' compensation insurance
Injury preferences
Light or modified duty available?

Drug screen after every work injury?

First-aid-only injury visits: bill your carrier or bill you?

Authorization

Fields marked * are required. You can also email a copy of your policy declarations page to Adama Touray at medex@medex1.org.