Facility Enrollment Form

Facility Application

Please review carefully and fill in requested data
Company Name
Legal Company Name
Contact*

First NameLast Name
E-mail*
Cellular Number*

Area CodePhone Number
Legal Address (for business)*

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Onboarding Date*

MonthDayYear
The date we add patients and go Live
Number of Subjects/Clients*
Total number of End Users
Number of Locations*
Total number of offices/houses
Address of Location 1*

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 2

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 3

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Address of Location 4

Legal Street Address for Personal Mail

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Note: Best practices suggest that at least 3 random test be requested over a 14 hour period or 4 schedulued test over a 14 hour period

Payment: IBAC will bill the insurer, if applicanble for the fees and services rendered. There will be no charges accessed to the sober living facility, unless specified in writing. The Facility Agreement will be emailed shortly after submission of this form. For assisstance please contact IBAC t 855-755-5200 or support@iBAC.com.
Testing Paremeters & Schedule:

Test request are sent via SMS and Push Notification, Patient has 90 minutes to submit a breath sample, Bac Level 0.00 and GPS Active.

Please select the desired program

Standard Program: One scheduled test at 8:00am & 10:00pm, plus 2 random Tests between 10:00am-8:00pm daily.

Custom Program: 4 scheduled and/or random test or a minimum of at least 3 random test daily.
Choose program for facility
Individual patients programs can still be customized under standard
Custom Program if needed - Select days for scheduled tests (Choose Multiple)

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
To Schedule Specific times. Enter times separated by Comma's or type "RANDOM"
Type times (3:30pm, 6:30pm, 9:00pm, etc)
Test Expires After

90 Minutes
Allow Client to See results
GPS Required
Monitors are immediately notified upon high BAC fails. We will monitor all other alerts and communicate any concerns.

OK / AgreedRequire something else
Primary Monitor*

First NameLast Name
Notify Agent by Email or Text*
Type Email OR Cell Number
Second Monitor

First NameLast Name
Notify Agent by Email or Text
Type Email OR Cell Number
Third Monitor

First NameLast Name
Notify Agent by Email or Text
Type Email OR Cell Number
In an effort to approve accountability, If a patient/subject misses 6 test over a two day period is it ok for our behavioral health expert to contact them for a brief 25 minute consultation?

YESNO
Do you currently bill insurance companies for Alcohol Breath Test or any Behavioral Health CPT Codes?

YESNO
If Yes please explain
Cpt Codes, Assessment, Laboratory etc
Who referred you? (iBac Rep, Individual, Company, Website, other)
Name of referral agent
Signature*

Clear
Type a question
Should be Empty:

Facility Application