Third Party Administrator Application

Company Info
Company Name*
DBA (if applicable)
Company Address*
Street Address Address Line 2 City State ZIP Code
- Same as billing address
Company Phone*
Company Fax
Company Web Address
Company FEIN*
Date of Incorporation*
MM slash DD slash YYYY
Contact Info
Contact Name*
First Last
Contact Phone*
Contact Phone (Mobile)
Contact Email*
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
Holding down Crtl will allow you to select multiple states.
Please indicate all states where you hold a laboratory license
Holding down Crtl will allow you to select multiple states.
Do you have relationships with labs that are SAMHSA certified?
- Yes
- No
Please provide list with site names, addresses and phone numbers
Drop files here or

Max. file size: 24 MB.
Do you offer consolidated billing from collection, labs and the MRO?
- Yes
- No
Please describe invoicing process
Name of Certified Medical Review Officer
First Last
Name of Laboratory Director
First Last
Please describe your compliance program
Please provide a copy of any compliance program materials (if applicable)
Drop files here or

Max. file size: 24 MB.
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
Drop files here or

Max. file size: 24 MB.
- 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
Product Name
Payment Info

This fee is non-refundable.
Total
$600.00
Billing Address*
Street Address Address Line 2 City State ZIP Code
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
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