Service Provider National Account

*AI*********Z*

AI*********Z

Instructions for Service Provider

This clinic requires an appointment!

Collom and Carney Clinic

**** * *** ****** *****

Prescott, AR 71857

870-***-****

Providers with eScreen123 must scan ePassport into eScreen123. Use eScreen Scheduled Event Account. Scan this barcode into eScreen123®

Instructions for HANSFORD LONG

Participant ID:

Account: 124439-1

SCI/Pre-Employment

This order must be completed by:

10/26/2018 12:04 PM (CT)

Account Type: National Account

Phone:

© 2017 Alere. All rights reserved. The Alere Logo, Alere, ePassport, eScreen, and eScreen123 are trademarks of the Alere group of companies. All other trademarks referenced are trademarks of their respective owners. MKT50274 REV2 6/17 Note: Completion time displayed does not mean that the service provider is open until the time shown. Note: Please visit the service provider's website or call to confirm operational hours.

Bill services to: eScreen, Inc., PO Box 25902,

Overland Park, KS 66225

• You are required to take a photo ID,

this ePassport, and all documents with

which it printed.

• If you are under 18, a parent or legal

guardian may be required in order for

services to be performed. Verify with

the service provider before arriving.

• Donor MUST take a non-DOT chain of

custody form to the collection site for

Fax: 870-***-**** this testing.

Services(1):

Regulation: NON-DOT

Reason for Test: Pre-employment

1. Urine Collection - 3124 - XC-9

PANEL (3124)

Contact this candidate