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
na
4
6
na
updateme@ncf.com
17
updateme@ncf.com
30
33
34
na
42
50
52
57
60
na
66
68
na
76
77
81
83
000001
89
93
95
97
100
104
105
111
112
116
na
119
122
127
updateme@ncf.com
141
updateme@ncf.com
00
na
NA
na
157
160
161
162
163
00
184
190
NA
updateme@ncf.com
194
197
201
na
203
na
updateme@ncf.com
215
na
219
220
222
228
230
updateme@ncf.com
NIK01
na
NA
240
242
247
245
n/a
262
263
265
267
271
274
279
278
283
285
286
289
293
296
298
n
304
311
313
na
322
00
329
NA
338
341
NA
344
357
358
360
364
367
777
NA
373
updateme@ncf.com
375
376
updateme@ncf.com
380
383
397
399
401
406
410
412
407
409
00
na
418
420
425
na
NA
427
no sales rep no seen
433
GTI
NA
na
00
452
458
459
467
Na
484
485
487
496
A01
updateme@ncf.com
updateme@ncf.com
NA
513
na
518
521
2001
na
na
435
007
N/A
na
na
557
NA
N/A
na
Additional notes