Keith Hartline
Flat Rock,AL
Overview
2
2
years of professional experience
Work History
BCR
PepsiCo
06.2023 - Current
Authorization Form
- FormFox Authorization - 80448786
- Vault Health Order ID - 2277705
- Questions: Please contact Vault Health at 800-732-3784
- All donors must bring this authorization form and a valid photo identification i.e. Driver's Licenses, Passport, etc. with them on the day of testing in order to proceed. The donor is urged to use either the full Donor ID or Employee ID listed below. Vault Health has a strong commitment to ensuring the privacy and confidentiality of donor's information and records.
- For FMCSA drug screen collections, please use Commercial Driver's License on the Custody and Control Form as the donor ID, in the following format: two (2) letter state abbreviation, followed by the license number without any dashes. (i.e. PA12345)
- Immediately after completing services, please Click Here to verify that all listed services on the authorization form have been completed.
- DONOR Hartline, Keith ID xxx-xx-4624 DOB 1980-07-17 TEST REASON Pre-Employment
- VALID 2023-06-06 09:30 EST EXPIRES 2023-06-08 09:30 EST
- REQUESTOR INFORMATION
- Pepsi Beverages Co/CHATN - 3609 AMNICOLA HIGHWAY CHATTANOOGA TN 37406 Phone: 914-334-0709
- Contact: Theresa Carbone
- CLINIC INFORMATION
- American Family Care - Lookout Valley - 3520 Cummings Hwy, Chattanooga, Tennessee 37419 Phone: 423-822-5942 Fax: 423-822-5946
- CLINIC HOURS
- Daily 8:00AM-6:00PM
- ORDERED SERVICES (1)
- You must perform ALL services listed below please look for Drug Screens AND Medical Services to be performed.
- DRUG SCREENS (1)
- PLEASE NOTE: Please send documents to documents@vaulthealth.com or fax to (215) 396-5610.
- Service Additional Forms & Instructions Electronic Specimen Type Agency Lab Account # Panel Split Observation Billing
- 1. NON DOT UDS No Yes Urine CRL NON FL8.NPEP.CHATN 30K0 No CS
- BILLING LEGEND
- CS - Urine drug screen collections & BATs must be billed to the address listed on the protocol. Please see attached.
- Authorization last updated as of 2023-06-06 09:51 AM.
Timeline
BCR
PepsiCo
06.2023 - Current
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