DRUG AND ALCOHOL TESTING REQUEST FORM



DRUG AND ALCOHOL TESTING REQUEST FORM

COMPANY: ____________________________ DATE: ___________________________

PHONE: _________________________ADDRESS: _____________________________

___________________________________________________________________________

DESIGNATED EMPLOYER REPRESENTATIVE (DER):________________________

EMPLOYEE NAME:________________________ EMPLOYEE ID: _______________

Please perform only the services marked with an x.

___DOT Drug Test ___NON DOT Drug Test _____DOT Breath Alcohol Test ____ DOT Physical

Reason for Test: (All Return to duty and Follow up testing must be performed under direct observation.)

___Pre Employment ____Random ____Return to Duty ____Reasonable Suspicion____

____Follow-up ___Post-Accident~ Date and time______________________________

TO CLINIC PERFORMING SERVICE: You may have both kits and chain of custody forms on file for this client. Or the donor will bring supplies with them. To order supplies call (802) 479-9201.

To ensure no disruption or delays in the turnaround time on drug test results, you must FAX the MRO copy of the Chain of Custody form immediately to the MRO. The MRO must have their copy of COC in order to verify and report all drug test results.

The MRO fax # is 413-525-9009

Lab: Clinical Reference Laboratory (CRL) MRO: Dr. Richard Brody

8433 Quivira 200 No. Main St.

Lenexa, KS 66215 E. Longmeadow, MA 01028

6917. 413 525-6003 FAX 413 525-9009

Third Party Administrator (TPA): ParaMed Plus, Inc.

27 Gable Place, Barre, VT 05641

802 479-9201 FAX 802 479-3574

Billing Information: Please bill ParaMed Plus, Inc. for your services.

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