| ACI/COATS Substance Abuse Program Account Setup |
| Open Printable Form |
Fax completed form to Midwest Toxicology Services - Fax Number: 317-262-2222
(* = required fileds)
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| Company Name:* |
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| Street/Address:* |
P.O. Box: |
| City:* |
State:* Zip:*
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| Phone:* |
Fax:* |
| Primary Contact Information: This should be the primary person responsible for the drug-testing program. All test results and confidential information will be communicated to this person. |
| Name:* |
Title/Position: |
| Phone:* |
Email: |
| Cell: |
Pager: |
| Alternate Contact if Primary Contact is unavailable: This person should be able to receive the same information that the Primary Contact receives. |
| Name: |
Title/Position: |
| Phone: |
Email: |
| Cell: |
Pager: |
| Company Contacts - for checking employee card status only: List other individuals you authorize to only check employee card status (not receive confidential information). NOTE: ONLY those listed below will be able to verify database card status. Future changes must be made by the primary or alternate contact in writing. |
| Name: |
Title/Position: |
| Name: |
Title/Position: |
| Name: |
Title/Position: |
| NOTE: All drug test results, ID cards and invoices will be mailed to the primary contact noted on the previous page. If your company requires the invoice to be mailed to a different person or place, please check the "yes" response below and provide additional information. |
| | Yes - Mail invoices separately to: |
| Attention: |
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| Street/Address: |
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| City: |
State: Zip:
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FEE CHARGED FOR DRUG TESTING PROGRAM & DATABASE ENTRY- ACI/COATS CARD:
$59.95 per drug test - This fee includes the following services associated with the COATS program:
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- Urine collection, SAMHSA lab testing & MRO review
- Entry of test results into ACI/COATS database
- Issuing a photo ID card on initial negative results
- Employee assistance on policy violations
- Locating & verification of SAP providers
- Management of testing problems and/or issues
- Management of random testing services
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- Secure database of employee testing records
- Secure web based card verification system
- Web access to check employee training
- On-going update & maintenance of database and website
- Database entry of employee 'training' history
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FEE CHARGED FOR DATABASE ENTRY & ACI/COATS CARD ONLY:
$15.95 per test entry - This fee includes the following services associated with the ACI/COATS program:
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- Entry of test result into ACI/COATS database
- Issuing a photo ID card
- Employee assistance on policy violations
- Locating & verification of SAP providers
- Management of testing problems and/or issues
- Database entry of employee 'training' history
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- Management of random testing services
- Secure database of employee testing records
- Secure web based card verification system
- Web access to check employee training
- On-going update & maintenance of database and website
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| INSTRUCTION FOR SUBMITTING TESTS TO MTS: |
- Fax a copy of each test result to 317-262-2222 with a cover sheet indicating the results are being submitted for the ACI/COATS program.
- The test result must contain the name of the SAMHSA laboratory, drug panel with cutoff levels, and MRO signature verifying review was completed.
- The results will be entered into the database; the ID card(s) and invoice will be mailed to the primary contact listed previously unless other direction is given for mailing cards.
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| CHECK TEST PANEL DESIGNATION: - if not designated, a 5-panel test will be set-up. |
| 5-Panel |
9-Panel (P&G Jobsites do require a 9-panel) |
| ACCOUNT DESIGNATION - Please check one below: |
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Company will be submitting outside test results for database entry and ACI/COATS card |
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Company will be using Midwest Toxicology Services for their drug testing program and for database entry and ACI/COATS card |
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At this time, extent of services is not known |
| ACCOUNT AUTHORIZATION AND VERIFICATION: |
Yes*, the company accepts the fees and terms noted above. The company agrees to pay all late fees assessed to past due invoices and will be responsible for all reasonable expenses involved in the collection efforts, including attorney's fees, court costs, and collection agency fees.
I am the person authorized to sign for the company; I am listed above as a primary or alternate contact.
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