ACCOUNT SET UP FORM
Prior to any samples received Account Set Up Form must be completed in its entirely ,or there will be a delay in processing.
CLIENT INFORMATION
Facility Name
Phone
Address
Address 2
City
State
ZIP Code
Preferred method of result notification :
Web Portal
HIPPA Fax #
Both
Initial Testing :
Tox
(Average per month
)
DNA
(Average per month
)
Blood
(Average per month
)
Others
(Average per month
)
CONTACT INFORMATION
Primary Contact Name
Title
Primary Contact Phone
Email
(Associated with Web Portal Log-in)
Physician Name
NPI#
SHIPPING INFORMATION
Requesting reoccurring pick up ?
Yes
NO (If no,please disregard the following 3 lines)
FedEx Account #
(If applicable)
Requested pick up date(s):
S
M
T
W
Th
F
Sat
ALL
Preferred pick up time
(Note 2 hours window)
Location of pick up (Front door,drop off door etc):
Close of business time:
Rep contact info
Select
12
51
25
78
53
78
041
54
78
56
77
83
1825
08
5
05
020
7327
025
122121212
3
042
50
52
19
6
17
81
11
07
55
002
3
75
82
1
1
010
002
86
15
027
09
030
000
81
83
2
87
12
18
007
026
987
85
00100
76
9087
01
10
80
04
008
06
Walter Loyola
Additional notes