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

CONTACT INFORMATION

Primary Contact Name

Title

Primary Contact Phone

Email (Associated with Web Portal Log-in)

Physician Name

NPI#