Common Contracts
1 similar Toxicology Services Provider Agreement contracts
Toxicology Services Provider AgreementToxicology Services Provider Agreement • August 29th, 2018
(To be completed by Provider) Completed NotApplicable 1. Provider Agreement: a. The clinic/organization name inserted on page 1 of the Provider Agreement matches the clinic/organization name on the current State of Alaska Business License and on the proof of Federal Tax Identification/Employer Identification Number (EIN). b. The Provider Agreement is signed by an individual authorized to enter into agreements on behalf of the clinic/organization. c. Printed name of the Provider representative is included on page 10. d. Contact information (phone/fax number and mailing/email address) is included on page 10. e. Entity type is identified on page 10. i. If an agency is applying as an Alaska Native Entity, a signed Waiver of Sovereign Immunity (Appendix B) is attached. 2. Copies of valid and current certifications for the Certified Substance Abuse Program Administrator (C-SAPA). 3. Copies of valid and current certifications for Medical Review Officer. 4
