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
TOXICOLOGY SERVICES PROVIDER AGREEMENTToxicology Services Provider Agreement • January 8th, 2021
, (Provider) enters into a Provider Agreement with the State of Alaska, Department of Health & Social Services (DHSS) for the purpose of providing drug testing services to referred Office of Children’s Services (OCS) clients for the State of Alaska’s Toxicology Program. By entering into this Provider Agreement, the Provider agrees to the following, including all applicable provisions of the following Appendices:
