Testing Program Onboarding & Service Authorization Form

Testing Program Onboarding & Service Authorization Form

Please complete this form to establish your testing coordination profile.
Organization Information
Legal Business or Practice Name*
Organization Type*
Primary Contact Name*

First NameLast Name
Primary Contact Title*
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Cities Where Testing Will Occur*
Test Program Details
DOT Drug & Alcohol ProgramNon-DOT Workplace Drug TestingCourt Ordered TestingDNA Testing ServicesClinical or Specialty Toxicology TestingAthletic/Sports Drug Testing ProgramOther
Ongoing Testing ProgramCase Specific Request
Testing Structure and Workflow
1-1415-2930-4950-99100+
RandomScheduledCourt MandatedPost IncidentReasonable SuspicionAs Needed
Employees/donors will report to a fixed collection siteWe need mobile/on-site collections at our facilityWe will use both depending on circumstances
YesNo
Clinical or Program Testing Structure
DOT Urine Drug PanelNon-DOT Urine Panels (5/10 panel)Oral Fluid Drug TestingClinical or Specialty Toxicology Testing (Behavioral Health / MAT Programs)Legal DNA Paternity TestingOther Relationship DNA TestingAthletic Drug Testing Panels (Standard / Steroid / League Specific)Other
YesNo
If yes, please list your desired panels.
YesNo
Compliance and Documentation
Court Admissible DocumentationEmployer Compliance RecordsClinical Documentation
YesNo
Authorized Results Recipient*

First NameLast Name
Title*
Email*
example@example.com
Only authorized recipients will receive testing results in accordance with applicable privacy and compliance standards.
Desired Service Start Date*

MonthDayYear
Date
YesNo
Decision Maker*

First NameLast Name
Title*
Client Acknowledgements and Consents
I understand that Great Expansion Enterprise LLC operates as a Medical Third-Party Administrator coordinating testing services through certified partner laboratories, mobile collectors, and collection sites. Specimen collection and laboratory analysis are performed by independent third party providers. Authorized recipients must be designated for result delivery, and electronic communication may be used for scheduling, coordination updates, and documentation. Final clinical decisions, employer policies, or legal determinations remain the responsibility of my organization or ordering party.
I consent to receive scheduling updates, coordination notices, invoices, and documentation electronically.
Signature*
Client Name*

First NameLast Name
Title*
Date*

MonthDayYear
Date
Should be Empty:

Testing Program Onboarding & Service Authorization Form

Organization Information

Test Program Details

Testing Structure and Workflow

Clinical or Program Testing Structure

Compliance and Documentation

Client Acknowledgements and Consents