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.
Select Account Type
Please select one of the following options
Facility
Pharmacy
Healthcare providers
Pharmacy Details
Facility/Pharm Name
*
Phone
*
Address
*
Address 2
City
*
State
*
Select
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
ZIP Code
*
Fax No
*
Facility / Pharmacy NPI
*
Pharmacy NCPDP
*
Primary Contact Name
Title
Primary Contact Phone
Primary Contact Email
Ordering Method :
Paper
Electronic
Preferred method of result notification :
Web Portal
HIPAA Fax #
EMR Direct
Automatic Patient Resulting
Initial Testing :
Tox
(Average per month
)
DNA
(Average per month
)
Blood
(Average per month
)
Others
(Average per month
)
CONTACT INFORMATION
Physician Name
*
Location ID
*
Critical Contact Details
Critical Contact Name
*
Critical Contact Phone Number
*
Critical contact Email
*
Pharmacist / Ordering Practitioner Details
Account Activation Type :
Email
Pharmacist / Ordering Practitioner Email
*
Password
*
Generate Password
Pharmacist / Ordering Practitioner Full Name
*
NPI#
*
NCPDP #
Need to hire new staff
Collector
Phlebotomist
None
Information For Phlebotomist
Yes
No
Special Requests
SHIPPING INFORMATION
UPS
FEDEX
Pickup Time Requested:
Requested pick up date(s):
Monday
Tuesday
Wednesday
Thursday
Friday
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