ACCOUNT SETUP FORM

Prior to sending any samples, you need to complete the Account Setup Form below, or there may be a delay in processing.

ACCOUNT SETUP FORM

CLIENT INFORMATION

Facility Name*

Phone*

Address*

Address 2

City*

State*

ZIP Code*

Fax No*

Federal

Commercial

Quickbook ID

Default Specimen COVID-19 *

HLOP

Mobile

STD Control

Client Bill

Dymo Printing

PharmD

This facility sends results to patients

Enable Auto Accession Generation

Add Location

CONTACT INFORMATION

Primary Contact Name*

Title

Primary Contact Phone*

Primary Contact Email*

Location ID

Critical Contact Details

Critical Contact Name

Critical Contact Phone Number

Critical contact Email

Ordering Method :

PaperElectronic

Preferred method of result notification :

Web PortalHIPAA Fax #EMR Direct

Add EMR Email*

Primary Physician Details

Account Activation Type :

Email
Username

Physician Full Name*

NPI# *

State License #

Add User

Special Requests

Specimen Pickup Information

UPSFEDEX

Pickup Time Requested:

Files

Success! Your file has been uploaded.

File	Date/Time		Delete

Assign Lab Code

id	Lab Name	Insurance Type	Test Type	Lab Code	Is Default	Requisition	Edit	Delete

Session Expiration

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notifications

ACCOUNT SETUP FORM

CLIENT INFORMATION

CONTACT INFORMATION

Primary Physician Details

Special Requests

Specimen Pickup Information

Projected Specimens