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
shawn_calvit22
4568456
Adam_Smith_001
142
Alle_Byeseda
WAG
Amy001
Anthany_Beatty_001
Anthony_Smith
AnthonyOcreo
anthony_tarwick
8925774
658098
Amy001-1002
BM_001
Billy_Novack_001
Bobby_Sturgeon_001
Brad_Delivories_1
Brandon_millikin_22
Brandon_Tibbetts
Brayton_Henson_22
Brendan_Pike_1
Breonna
Brian_Bailey_001
Brian_LaPorta
Xeno
Brigham_Buhler_001
Britt_1234
Carl_Hurd_001
Casey121
Chad_001
Chad_Wise_11
CC_001
Chance_123
Charles_Beauford_22
Chelsea_Soden_001
TNC_Health_Solutions
Chike_001
Chris_Cruz_001
Chris_Cardenas_001
238947
Chris_Sudduth
Amy001-1008
CDM
Chuck_Kasbee_001
23459952
6734869
Craig_123
Bobby_Sturgeon_001-Craig_Ball_001
Pat_123
MedTec
Dan_Dood
Danel1234
daniel123
Daniel_123
101
77
Advent01
David_Mosberg_1
Dawne_Era
Deepak_Belani_1
Amy001-1006
Derick_Johnson_1
Desmond_white
Dream_Catcher001
Ed_Kostishion_1
EH01
Eric_Cullen_001
ES01
fabian_calvo
Ft01
5900772
Amy001-1009
Gian_Luca_001
test_haroon
Heathe_May123
IQM
Jackie_Tamulski_11
James_Feeley_1
4432350
Jamie_Nocher_001
Janson_woodley444
jason_lavoie
Jason_Megginson
JB
Amy001-1012
Jeff_Wayne_001
Jeffrey_Sardisco_001
jennifer_bugzis33
Jennifer_Sears
Jerrod_smith@truemedit.com
Joel_French_1
Amy001-1007
Whitehouse
1
23671061
Jonah_adler
Jord_123
Jordan_Miller_322
4932686
Josh1231
Joshua_ Ross_22
5468486
Joyce_Hinds
Julie_gadbois
342342
1
Kady_Svensson_001
Kellen_Oldham_112
Ken_123
RMKMV
kim_sch_333
Kimberly_Dominguez_44
Kyle_123
638373
Laura_Job_001
rep
4207149
LN1
lola_hernandez33
LD01
9263794
Mark_Frank_221
45568486
78349748
Matt_Klein22
Matt_Dynes_001
THRM01
890
l91
na
mof
Mike_Henderson_221
Mike_Fitch_001
Mike_Nolan_001
A
Preventive_Health_001-4
Neel_123
LS01
4338250
8736457
O
23437240
237688383
Patrick123
Paula_Pirone_221
Phil_123
B01-B02
B01
TM04
TM03
premier-health33
Preventive_Health_001
Raymond_Jackson_001
raymond_123
Remn_001
484484
Richard Justin Etling
Rick_123
rob_watson
Robbie_Johnson_112
Robert_Takiya_001
RC01
6197190446
Roni_Hersk
ross_pellersels
Rowdy_Stovall_43
RFR_Support444
R123
Ryan_Smith_22
MSM01
Ryan_Herting_123
Ryan Needle
142
SS01
Shane_123
Sharhonda_walker_11
Shawn_Kaser_001
Shelda_Keith_001
Jennifer_senter44
Stephanie_123
003
Tara_Fosterz_55
1234
Terry_McNamara_1
TM01
23432
343
Mervg01
Tim_123
Tina_Ball_22
TomTest
Tom_Smid_1
TPHM
Vinson_Woodlee_001
Amy001-1
WG
YR001
Yvonne_001
Additional notes