THIRD PARTY CLIENT ACCOUNTS THIRD PARTY CLIENT ACCOUNTS Precision Rep Name: * Company Name: * Company DER: * DER Contact Phone #: DER Email Address: * Method of Testing Urine Hair Blood Panels to be tested * 5 Panel 10 Panel 12 Panel BAT ETG (80 Hour) ALC (8 Hour) Other Other: How will the client make a payment? * Upfront Payment (no card on file) Invoice (card must be on file) Check Other Other Payment Method Are we sending CCFs to clients? * YES NO SEND CCFS TO TPA COLLECTOR SITE Mailing Address for CCF: Select all that apply: * DOT (Department of Transportation) Non-DOT observed rapid test Body hair On-Site Emergency After Hours Post Accidents Pre-Employment Reasonable Suspicion Random LAB BEING USED: * QUEST LABCORP OTHER If Rapid, are we sending rapid form to TPA? * YES NO TPA Company Name: TPA Rep you spoke to: * TPA Phone # * TPA Address: * Select whatever applies TPA Requires payment upfront TPA Can send us an invoice TPA full service collections only On-sites After Hours Same day On-site BAT OUR TEST COST * (Whatever panel is being tested) $ OUR ON-SITE FEE $ TPA Collection Fee $ TPA On-site Fee (If Applicable) $ Additional Details/Pricing/Protocol: Was a protocol and agreement sent to the TPA? * YES NO WORKING ON IT Thank you!