subject_line
Account Setup
.
Save & Return
Use an account to return to saved work.
Log in
Form Submitter
*
Sales Representative's Full Name
*
Who is the Market Executive for this account?
*
Account Manager's Full Name
Account Details
NOTE: Start date must be at least one week from form submission date to ensure all aspects can be setup prior to launch.
Account Desired Start Date:
*
+
Definitive Data ID Number
Clinic Name:
*
Clinic Address:
*
Clinic City:
*
Clinic State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Clinic Zip code:
*
Account Contact Information
Primary Contact Name:
*
Primary Contact Email:
*
Clinic Phone Number:
*
Clinic Phone Extension
Clinic Fax Number:
Clinic Billing Contact Name:
*
Clinic Billing Contact Number:
*
Billing Contact Phone Extension
Billing Contact Email:
*
Billing Fax Number:
Preferred Billing Contact Method
Email
Phone
Account Hours of Operation
Add Entry
The minimum number of rows for the section is 1
Days Open:
*
Monday - Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours
Minutes
..
Opening Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Hours
Minutes
..
Closing Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Add Entry
Days Open:
*
Monday - Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours
Minutes
..
Opening Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Hours
Minutes
..
Closing Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Add Entry
Days Open:
*
Monday - Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours
Minutes
..
Opening Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Hours
Minutes
..
Closing Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Add Entry
Days Open:
*
Monday - Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours
Minutes
..
Opening Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Hours
Minutes
..
Closing Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Add Entry
Days Open:
*
Monday - Friday
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Hours
Minutes
..
Opening Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Hours
Minutes
..
Closing Time:
1
2
3
4
5
6
7
8
9
10
11
12
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
AM
PM
Specimen Collection Specifics
What type(s) of account(s) are you signing up?
*
Blood
Urine Toxicology
Oral Toxicology
PGx
Covid-19
Is an authorized clinic
representative available to
sign the Urine Drug Test Policy?
*
Yes
No
Please Click the Link below:
Urine Drug Test Policy
.
A link with the Urine Drug Test Policy Form for the Provider to sign and complete will be sent via email.
Provider Name
*
Provider NPI Number
*
Provider's Email:
*
.
Estimated Weekly Sample Volume: Blood
*
Estimated Weekly Sample Volume: Urine Toxicology
*
Estimated Weekly Sample Volume: Oral Toxicology
*
Estimated Weekly Sample Volume: PGx
*
Estimated Weekly Sample Volume: Covid-19
*
Sum of Weekly Volume:
0.00
Calculate
NOTE: Total volume cannot be zero.