• According to the US Department of Transportation rules and regulations a company can have a service agent provide or coordinate the provision of a variety of drug and alcohol testing services to employers. Included in these regulations are requirements that the providers of the drug and alcohol C/TPAs and MROs are certified according to the standards and drug testing procedures required under 49 CFR Part 40. KTHC is compliant with all requirements required under 49 CFR Part 40. If your company is electing to have KTHC as your DOT Service Agent, Complete the form below.
  • Contract Term January 1 to December 31, 2020. This agreement expires 12/31/20 and will automatically renew for subsequent 12 month periods per the terms listed below.
  • *Please note that KTHC sends results, billing and informational documents to your email address. We request that your email be kept secure due to sensitive information that may be transmitted.
  • Random Selection Provider

  • Please circle “Yes” below if you would like for us to pull your random drug screens and alcohol selections, and would like us to pull your Clearinghouse Query’s. By selecting YES, Motor carrier agrees to send a complete list of all drivers to KT Health Clinic when requested. Minimum will be each six months – December and June – for random selections.
  • Please circle “Yes” below if you would like for us to conduct your required Clearinghouse Query’s By selecting yes, Motor carrier agrees to comply with Clearinghouse requirements for conducting Query’s and will complete all necessary items for KT Health to conduct Query’s on your behalf.
  • **KTHC Fee per Query is $10 , Clearinghouse Query’s are required for all new hires (Pre-employment), and all Active Drivers 1x annually. KTHC is not responsible for fees charged to motor carrier by FMCSA for clearinghouse activities.
  • Please list up to three Designated Employee Representatives that we can discuss drug screen results with:
  • ***This agreement expires December 31, 2020 and will be automatically renewed indefinitely for additional 12 month terms beginning January 1st of the following term year(s). The $100 Consortium annual fee is due on December 1st each year and will be charged to credit card on file unless terminated in writing with a minimum of 30-days notice prior to end of current contract year. All clearinghouse Query fees will be charged as incurred. ***KTHC reserves the right to terminate this agreement with no notice with motor carriers that do not actively participate or Meet requirements of our DOT consortium. Signing below indicates your agreement and understanding.
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