PHMSA Consortium

PHMSA Consortium

Louisiana Occupational Health Services
How can LOHS help your business sort through the tough DOT/PHMSA testing requirements?

LOHS will manage this all for you! We have designed this consortium program to be the most ideal and efficient process for any company needing to comply with DOT/PHMSA drug and alcohol testing regulations 49 CFR 199. We will be reliable and reachable when questions or changes to your account should arise. Helping to keep you in DOT/PHMSA compliance is important to us here at LOHS and we ensure a dependable partnership to accomplish this.
LOHS – PHMSA Consortium membership includes:
- Manage Drug Random Pool Program
- Maintain Drug Program Records
- Anti-Drug and Alcohol Misuse Program Policy
- Certificate of Consortium Enrollment
- SAP Referral Information
- MRO Services
- No MONTHLY FEES
Consortium Membership Fees
- $99.00 Per Enrolled Employee/Per Year (this is the cost for Non-DOT employees also)
- $50.00 Anti-Drug and Alcohol Misuse Policy
- $30.00 Annual Policy Update
Additional Services Available:
- Supervisor Reasonable Suspicion Training - $75.00 Per Supervisor
- Annual MIS Reporting - $75.00
- Any other data reporting - $75.00 per report
- DOT Drug Screen - $50.00 @ LOHS
- DOT Breath Alcohol - $20.00 @ LOHS
- MRO - $35.00 (fee if collection is performed outside of LOHS)
*NEW DOT pre-employment drug screens will be required upon enrollment for every enrolling employee. No refund will be issued due to cancelation of enrollment during the enrolled period.

PHMSA Consortium Account Information

Louisiana Occupational Health Services
Company Information*
Company Name/Municipality
Tax ID#*
OPID#
Contact Person/Company's DER*

First NameLast Name
Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Restricted Release Information
I authorize the below personnel, ONLY, to obtain employee medical information and/or drug screen results via email, fax, and/or verbal reports from Louisiana Occupational Health Services. I confirm the below personnel will maintain confidentiality with regards to any and all reports received. The company agrees to update this form in the event any authorized personnel changes are made. All medical information and drug screen results will be PORTAL ACCESS or EMAILED to the following personnel. Please select which option(s) are preferred. NOTE: If you choose to utilize our PORTAL for RESULTING please select PORTAL in the result source below and we will get it set up for you.
Select ONE Result Source*
Authorized Personnel to receive Employee Medical Information*

First NameLast Name
Email for resulting or portal access to be sent to.*
example@example.com

PHMSA CONSORTIUM ENROLLMENT LIST

Louisiana Occupational Health Services
Total number of employees performing covered functions in Appendix D who are under this Substance Abuse Plan, including those within OpID No’s or BTIN No’s. listed above. Refer to the operator’s most recent Management Information System (MIS) or statistical drug and alcohol testing report in Appendix N.*
Total Number of Gas/PHMSA covered employees
Does your company have to report Statistical Data to any other entities? (example NCMS) *
IF YES, please list here the additional entities here.
LIST ALL DOT/PHMSA EMPLOYEES NEEDING TO BE ENROLLED

(SCROLL ALL THE WAY TO THE BOTTOM TO SUBMIT)
List PHMSA Employees below - $99.00 per PHMSA employee/per year
Do you need to enroll any Non-DOT employees?
List Non-DOT Employees below - $99.00 per Non-DOT employee/per year
Authorized Representative*

First NameLast Name
Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Louisiana Occupational Health Services - 3018 Jackson St., St. 100, Alexandria, LA 71301

P:(318)561-8200 F:(318)561-8204 www.lohs.net
Should be Empty:

PHMSA Consortium

PHMSA Consortium Account Information

Restricted Release Information

PHMSA CONSORTIUM ENROLLMENT LIST

LIST ALL DOT/PHMSA EMPLOYEES NEEDING TO BE ENROLLED