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MM slash DD slash YYYY
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Additional Info
Please list all Owner, Partners, Officers and Directors
Please list the Name, Title, and Percentage Ownership of each owner
Name
Title
Ownership Percentage
Please indicate all states where you are licensed to do business
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Iowa
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Texas
Utah
Vermont
Virginia
Washington
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Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
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Holding down Crtl will allow you to select multiple states.
Please indicate all states where you hold a laboratory license
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Holding down Crtl will allow you to select multiple states.
Do you have relationships with labs that are SAMHSA certified?
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No
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Do you offer consolidated billing from collection, labs and the MRO?
Yes
No
Please describe invoicing process
Name of Certified Medical Review Officer
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Last
Name of Laboratory Director
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Last
Please describe your compliance program
Please provide a copy of any compliance program materials (if applicable)
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Please describe the privacy and security safeguards the entity uses to protect individually identifiable information
Do you have electronic chain of custody forms available?
Yes
No
Can you facilitate the setup of drug testing anywhere in the nation with no additional charge?
Yes
No
Do you have certified trainers on staff? (collection, BAT, STT)
Yes
No
Are you a member of a national drug testing, drug prevention organization such as DATIA?
Yes
No
Will you participate in an annual audit of your testing as part of our program?
Yes
No
Do you provide EAP services?
Yes
No
Has the applicant or any entity that controls the applicant, or any owner, partner, officer or director ever been convicted of, or is the applicant, or any owner, partner, officer or director currently charged with, committing a crime, whether or not adjudication was withheld?
Yes
No
“Crime” includes a misdemeanor, felony or a military offense. You may exclude misdemeanor traffic citation and juvenile offenses. “Convicted” includes, but is not limited to, having been found guilty by verdict of a judge or jury, having entered a plea of guilty or no contest, or having been given probation, a suspended sentence or a fine.
Please include a written statement explaining the circumstances of the incident.
Please attach additional documentation
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Licenses, Certifications and Accreditations – Please provide copies of all licenses and certifications (including, but not limited to, federal and state) and any accreditations
Memberships – Please attach a copy of any memberships the entity holds
Certified Financials for the past three years
Certificate of Insurance and Surety Bond
Please provide three professional references
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Street Address
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City
Alabama
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American Samoa
Arizona
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California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
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North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
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Washington
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Wisconsin
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Armed Forces Americas
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