Onbarding Link for Colorado sober living facilities

DMP / ASP Enrollment Form

Please review carefully and fill in requested data
Company Name
Legal Company Name
Contact*

First NameLast Name
E-mail*
Cellular Number*

Area CodePhone Number
Legal Address (for business)*

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Onboarding Date*

MonthDayYear
The date we add subjects and go Live
Number of Subjects/Clients*
Total number of End Users
Number of Locations*
Total number of offices/houses
Address of Location 1*

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 2

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 3

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 4

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Note: Best practices suggest that at least 2 random test be requested over a 13 hour period or 4 schedulued test over a 13 hour period

Payment: IBAC will bill the insurer, if applicanble for the fes and services rendered. There will be no charges accessed to the sober living facility, unless specified in writing. This Enrollment form is accompanied with an ASP contract. For assisstance please contact IBAC at 855-755-5200 or support@iBAC.com.
Schedule 1 - Select days for scheduled tests (Choose Multiple)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
To Schedule Specific times. Enter times separated by Comma's or type "RANDOM"
Type times (3:30pm, 6:30pm, 9:00pm, etc)
Schedule 2 - Select days for scheduled tests (Choose Multiple)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
To Schedule Specific times. Enter times separated by Comma's or type "RANDOM"
Type times (3:30pm, 6:30pm, 9:00pm, etc)
Test Expires After

30 Minutes60 Minutes90 Minutes120 Minutes
Allow Client to See results
GPS Required
Notify Monitors When

Test PassedTest FailedTest ExpiredOptional Test PassedOptional Test Failed
Primary Agent*

First NameLast Name
Notify Agent by Email or Text*
Type Email OR Cell Number
Second Agent

First NameLast Name
Notify Agent by Email or Text
Type Email OR Cell Number
Third Agent

First NameLast Name
Notify Agent by Email or Text
Type Email OR Cell Number
Who Referred You*
Signature*

Clear
Should be Empty:

DMP / ASP Enrollment Form