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*

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

$0.00

Billing Address*

Street Address Address Line 2 City State ZIP Code

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

CAPTCHA

Company Info

Contact Info

Additional Info

Payment Info

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Program

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2024 CCS Safety Series

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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

Third Party Administrator Application

Company Info

Contact Info

Additional Info

Payment Info

Certification Program

Substance Abuse Program

Worker Training Database

Certification
Program

Substance Abuse
Program

Worker Training
Database