| COATS Substance Abuse Program Database Administrator Account Setup & Agreement For Services |
| 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. The MRO service will contact this person by telephone to communicate positive test results or other problems. |
| 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 who are eligible to call the database to verify card status: List other individuals who are authorized to call the database to verify card status. NOTE: ONLY those listed will be able to verify database card status. Any future changes (removing or adding individuals) must be made by the primary or alternate contact in writing. (List additional names on a separate page) |
| Name: |
Title/Position: |
| Name: |
Title/Position: |
| Name: |
Title/Position: |
| FEE CHARGED FOR DRUG TESTING PROGRAM & DATABASE ENTRY/COATS CARD: $59.95 per drug test - This fee includes the following services associated with the COATS program: |
- Urine collection, SAMHSA laboratory testing and MRO review of each test
- Entry of test results into COATS database
- Issuing the COATS card on negative results
- Management of SAP providers and SAP referral information for the employee who tests positive
- Management of return-to-duty and follow-up testing
- Professional assistance and/or referral for help with policy review/development, random selections, education & training for employees & supervisors, etc.
- COATS will utilize part of this fee for the advancement of substance abuse prevention and policy as well as for promotion of construction industry safety improvements
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| Check test panel designation - if not designated, a 5-panel test will be set-up. |
| 5-Panel |
9-Panel (for P&G Jobsites and Argosy Casino Expansion [Penn National Gaming Inc. (Owner) & Messer Harmon LLC]) |
| NOTE: All drug test results, COATS 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 DATABASE ENTRY/COATS CARD ONLY: $15.95 per test entry - This fee includes the following services associated with the COATS program: |
- Entry of test result into COATS database
- Entry of test results into COATS database
- Issuing the COATS card on negative results
- Management of SAP providers
- SAP referral information for the employee who tests positive
- Management of return-to-duty and follow-up testing
- COATS will utilize part of this fee for the advancement of substance abuse prevention and policy as well as for promotion of construction industry safety improvements
|
| NOTE: To submit test results to the database, fax a copy of the test result to 317-262-2222. 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. |
| ACCOUNT DESIGNATION - Please check one below: |
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Company will be submitting outside test results for database entry/COATS card |
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Company will be using Midwest Toxicology Services for their drug testing program and for database entry/COATS card |
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At this time, extent of services is not known |
| RANDOM CONSORTIUM TESTING (Optional): |
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" Please check if you would like information on our consortium that is available through Midwest Toxicology Services. This consortium currently tests at a 5% annual random rate. |
| 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.
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