Legacy Health System - How To Find UsComplete this form and either fax a
printed version to 503-413-4621 or submit electronically to Legacy Laboratory Services - Toxicology by using
the "Submit" button at the bottom of the form. Please call Client Services at
503-413-5295 or 800-950-5295 or email Legacy Toxicology if you have any questions or need
assistance.
Demographic Information
Items with red arrows ( ) are required.
Substance Abuse Policy
Do you have a written substance
abuse policy in place?
Yes No
If yes, have your employees been
notified?
Yes No
Testing
Employees regulated by DOT, FHA, FAA or Coast Guard are subject
to a federally mandated protocol under the Substance Abuse and Mental
Health Services Administration (SAMHSA).
For information about
federal regulations, including 49 CRF Part 40, Procedures for
Transportation Workplace Drug and Alcohol Testing Programs, see the Department of Transportation.
Category
SAMHSA (federally mandated protocol)
SAMHSA
Random Selection by
Non-SAMHSA (see protocol choices below)
Testing Protocol (Non-SAMHSA) Indicate each purpose for testing; choose panel
desired under each purpose from Panel menu; indicate option for evidential
breath alcohol testing from Breath Alcohol menu.
Click
here for Drug Testing Collection Sites (including maps) in the
Portland/Vancouver area. Collection sites outside the
Portland/Vancouver area are required YesNo
Confidentiality and Contacts
Results or
account information will be discussed only with authorized company
contacts, including a Medical Review Officer (MRO) by your optional
designation.
Primary
Contact:
Phone Number: () -
Secondary
Contact:
Phone Number: () -
MRO Name:
Phone Number: () -
MRO Address:
Fax Number: () -
Results Reporting Options
SAMHSA
(DOT) (All SAMHSA results must be reported directly to your MRO.
Skip to "Invoice Instructions" as there is no need for you to
complete the remainder of this section.) Non-DOT -- select one of each
of the options below.
Report
Results to authorized company contacts:
Fax Report to Secure Fax
#()--
(Secure Agreement will be faxed for signature)
IVR -Interactive Voice Response
& Mailed Report to Primary Contact. Use your unique
telephone code to access confidential reports at your
convenience.
Send Results to Medical Review Officer (MRO) for
evaluation? (Click here for MRO Definition.)
Yes, send ALL Results to the
MRO. Send no results directly to company. Yes, send Positive Results Only to the
MRO. Report negatives to authorized company contacts. No, MRO evaluation is not
requested at this time. Report all results directly to company
contacts.
Invoice
Instructions
Legacy Toxicology mails invoices at the beginning of each month for
services provided during the previous month. Payment is expected
within 30 days from date of invoice. Please send invoice to:
Primary
Contact at Mailing Address in demographic information.
Other name
and address below.
Accounts Payable
Contact Phone Number:
() -
Address
City
State
Zip Code +
Please submit questions or
special account information
Information submitted will be confirmed
with you by a Legacy Toxicology representative prior to account activation.
) are required.
