PMP Consortium Enrollment

802.793.7496

2688 Roy Mtn Rd E. Ryegate VT 05042
Thank you for choosing to join the ParaMed Plus Consortium.

This enrollment form will take approximately 5 -10 min to complete.

Businesses with a large list of drivers may find it helpful to have their list ready in spreadhseet format for upload. Drivers can also be entered manually on the drivers information page.

Please contact ethans@paramedplus if you have any questions about enrollment or need help with this form.
Date

MonthDayYear
Date

Business Information
Who is this enrollment for:*

Business/EnterpriseOwner Operator
Designated Employer Representative

First NameLast Name
Owner Operator Name

First NameLast Name
Business Name
DOT Number
Phone Number*
Please enter a valid phone number.
Fax
Please enter a valid phone number.
Email*
example@example.com
Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Driver Information

Businesses with more than a few drivers may find it easier to upload a list of all current drivers in an excel spreadsheet. Both uploaded lists or manual entries must contain the following information for every driver:

Driver Name
D.O.B.
CDL# and State of Issue
Upload Driver List

List must contain the following for every driver: 1) Driver Name 2) DOB 3) CDL# and State of Issue
Cancelof
FMCSA Clearinghouse Services

Per the FMCSA:

Employers: May designate a consortium/third-party administrator (C/TPA) in the Clearinghouse to assist with meeting their query and violation reporting requirements.

Owner Operators: Must authorize at least one consortium/third party administrator (C/TPA) to meet their query and violation reporting requirements.
C/TPA

I am designating ParaMed Plus as my C/TPA with FMCSA Clearinghouse.I do not wish to use Paramed Plus as my C/TPA with FMSCA Clearinghouse.
Choose which services you would like ParaMed Plus to provide:

Annual Limited Query (Required for owner operators)Pre-Employment/Full Query (Required for owner operators)Report Violations (Required for owner operators)Report Return to Duty Test Results
C/TPA Services Agreement

ParaMed Plus, Inc. agrees to perform the services listed above on the employer’s behalf as permitted within the FMCSA Clearinghouse. This agreement will remain in existence as long as the above-mentioned employer is a member of the ParaMed Plus, Inc. Consortium. Either party may cancel this agreement at any time.

Fees
- Report Violation and Return to Duty results – no fee
- Pre-Employment Query/Full Query $8.00/query (fee will be added to drug test fee)
- Annual Query $5.00/query or Minimum fee $15.00
Employer must maintain a query balance amount adequate for the queries to be conducted. ParaMed Plus, Inc. is not allowed to purchase query plans on behalf of the employer.
Signature*

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{ownerOperator}
Owner Operator
{designatedEmployer}
Designated Employer Representative
{date}
Enrollment Contract

ParaMed Plus, Inc. agrees to provide Third Party Administration of a DOT drug and
alcohol testing program to:
{ownerOperator}
{physicalAddress}
{businessName}
{physicalAddress}
This agreement will remain in existence for an unlimited period of time and commence on {date}. Either party may cancel this agreement by submitting written notification to cancel this agreement.

{ownerOperator} agrees to maintain compliance with all aspects of the Federal Motor Carriers Safety Administration’s, (FMCSA) Drug and Alcohol Testing Regulations. This agreement will be canceled by ParaMed Plus, Inc. for nonpayment of services or for uncorrected noncompliance with Federal Regulations.

ParaMed Plus, Inc. acting as a Third Party Administrator for your company is allowed to act as an intermediary in the transmission of drug and alcohol testing results. This is allowed provided a written agreement exists between the employer and ParaMed Plus, Inc. This document is intended to serve as our written agreement.

At the request of {ownerOperator}, ParaMed Plus, Inc. will act as an intermediary in the transmission of drug and alcohol test results.

Please maintain a copy of this document in your drug and alcohol testing files.
This agreement will remain in existence for an unlimited period of time and commence on {date}. Either party may cancel this agreement by submitting written notification to cancel this agreement.

{businessName} agrees to maintain compliance with all aspects of the Federal Motor Carriers Safety Administration’s, (FMCSA) Drug and Alcohol Testing Regulations. This agreement will be canceled by ParaMed Plus, Inc. for nonpayment of services or for uncorrected noncompliance with Federal Regulations.

ParaMed Plus, Inc. acting as a Third Party Administrator for your company is allowed to act as an intermediary in the transmission of drug and alcohol testing results. This is allowed provided a written agreement exists between the employer and ParaMed Plus, Inc. This document is intended to serve as our written agreement.

At the request of {businessName}, ParaMed Plus, Inc. will act as an intermediary in the transmission of drug and alcohol test results.

Please maintain a copy of this document in your drug and alcohol testing files.
Signature*

Powered by Jotform SignClear
{ownerOperator}
Owner Operator
{designatedEmployer}
Designated Employer Representative
{date}
Should be Empty:

802.793.7496

Business Information

Driver Information

FMCSA Clearinghouse Services

C/TPA Services Agreement

Enrollment Contract