Clinical Drug Testing Program Intake Form
Complete all sections below. Fields marked with * are required. A member of our team will follow up within 1 business day.
DATE RECEIVE
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Month
-
Day
Year
Date
01 ORGANIZATION INFORMATION
ORGANIZATION / FACILITY NAME *
*
ORGANIZATION TYPE *
*
PRIMARY CONTACT NAME *
*
TITLE / ROLE *
*
PHONE NUMBER *
*
Format: (000) 000-0000.
EMAIL ADDRESS *
*
example@example.com
FACILITY / MAILING ADDRESS *
*
BEST CONTACT METHOD
PREFERRED CONTACT TIME
02 CLIENT POPULATION & PROGRAM SIZE
APPROX. CLIENTS/EMPLOYEES TESTED MONTH
TESTING FREQUENCY *
*
COLLECTION LOCATION
POPULATION DESCRIPTION (optional)
03 TESTING SERVICES REQUESTED
SELECT ALL SERVICES THAT APPLY *
Testing Services
*
Rapid Urine Drug Screening
Lab-Confirmed Urine Testing
Oral / Saliva Testing
Hair Follicle Testing
Nail Testing
Breath Alcohol Testing (BAT)
Customized Drug Panel Design
Mobile / On-Site Collection
SUBSTANCES OF PRIMARY CONCERN
(check all that apply)
Substances of Primary Concern
Opioids / Opiates
Fentanyl
Buprenorphine / Suboxone
Methamphetamine
Cocaine / Crack
THC / Marijuana
Benzodiazepines
Alcohol (EtG)
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Amphetamines / ADHD Meds
Other Prescription Monitoring
OTHER SUBSTANCES / SPECIFIC PANEL REQUIREMENTS (optional)
04 RESULTS DELIVERY & REPORTING PREFERENCES
PREFERRED RESULT DELIVERY METHOD *
*
REQUIRED TURNAROUND TIME *
*
FAX NUMBER (if applicable)
SECONDARY / RESULTS CONTACT EMAIL (optional)
example@example.com
DO YOU HAVE AN EXISTING DRUG TESTING POLICY?*
*
Yes - I will share it with M2Z
No I need help creating one
No - not required for our program
SAP OR MRO CURRENTLY ON FILE? (optional)
CURRENT TESTING VENDOR / LAB (optional - leave blank if none)
05 BILLING & ACCOUNT SETUP
BILLING CONTACT NAME (if different from above)
BILLING EMAIL ADDRESS (optional)
example@example.com
BILLING ADDRESS (if different from facility address)
PREFERRED PAYMENT METHOD
PURCHASE ORDER # OR ACCOUNT CODE (optional)
TAX-EXEMPT STATUS (optional)
06 ADDITIONAL CONTEXT & QUESTIONS
HOW DID YOU HEAR ABOUT M2Z? (optional)
DESIRED PROGRAM START TIMELINE (optional)
ADDITIONAL NOTES, QUESTIONS, OR SPECIAL REQUIREMENTS (optional)
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07 AUTHORIZATION & SIGNATURE
DISCLAIMER & HIPAA NOTICE
M2Z Compliance Solutions does not provide medical diagnosis or treatment. All testing is for informational and monitoring purposes only; results should be reviewed by a qualified healthcare professional. All data and client information submitted are handled in accordance with HIPAA standards. By signing below, I confirm that the information provided is accurate and that I am authorized to request testing services on behalf of the organization listed above.
AUTHORIZED SIGNATURE *
*
DATE *
*
-
Month
-
Day
Year
Date
PRINTED NAME & TITLE *
*
FOR OFFICE USE ONLY
DESIGNED BY
DATE ENTERED
ACCOUNT #
ASSIGNED REP
FOLLOW UP DATE
STATUS
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