Consortium Enrollment

Reliable & Accurate Results

Secure Health Partners is the trusted lab screening partner for many businesses, schools, court systems, DOT-regulated organizations and corporations. Do you need to order a consortium enrollment? Fill out the form below.

Date: Company Name: New Reinstatement
Main Contact Name:   Billing Contact: Same
Mailing Address: Physical Address: Same Billing Address:Same
City, State, Zip City, State, Zip City, State, Zip

Email:
Who Referred You To Our Consortium?
# Of Employees:



List those authorized to receive drug screen results and preferred method below.
For participant list, either list below or email an .xls or .csv file to info@securehealthpartners.com.

  phone/fax/email:
  phone/fax/email:
  phone/fax/email:
     
Type Of Business:
 
Employee Name Social Security Or Employer ID #
 
Are you currently enrolled in a Random Drug Testing Program? Yes No
If Yes, Consortium Name:
Type of testing your company requires: DOT Non-Dot


Please Note: All DOT Employees Must Provide Proof Of a Negative Drug Test, or Previous Consortium Enrollment, Before They Will Be Enrolled In The Consortium Program.

To Use A Previous Drug Test, It Must Have Been Taken Within 30 Days Prior To Joining The Consortium


With my signature, I hereby agree to participate in Secure Health Partners consortium and further agree to abide by its rules, policies and procedures. Upon receipt of my signed application and payment, Secure Health Partners will forward me a complete membership package, which will include proof of membership and rules and regulations.

Authorization Signature: Date: