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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
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CLIENT INFORMATION
Facility Name
*
Phone
*
Address
*
Address 2
Latitude
Longitude
City
*
State
*
Select
Alabama (AL)
Alaska (AK)
Arizona (AZ)
Arkansas (AR)
California (CA)
Colorado (CO)
Connecticut (CT)
Delaware (DE)
District of Columbia (DC)
Florida (FL)
Georgia (GA)
Hawaii (HI)
Idaho (ID)
Illinois (IL)
Indiana (IN)
Iowa (IA)
Kansas (KS)
Kentucky (KY)
Louisiana (LA)
Maine (ME)
Maryland (MD)
Massachusetts (MA)
Michigan (MI)
Minnesota (MN)
Mississippi (MS)
Missouri (MO)
Montana (MT)
Nebraska (NE)
Nevada (NV)
New Hampshire (NH)
New Jersey (NJ)
New Mexico (NM)
New York (NY)
North Carolina (NC)
North Dakota (ND)
Ohio (OH)
Oklahoma (OK)
Oregon (OR)
Pennsylvania (PA)
Rhode Island (RI)
South Carolina (SC)
South Dakota (SD)
Tennessee (TN)
Texas (TX)
Utah (UT)
Vermont (VT)
Virginia (VA)
Washington (WA)
West Virginia (WV)
Wisconsin (WI)
Wyoming (WY)
ZIP Code
*
Fax No
*
Federal
Commercial
Default Specimen COVID-19
Sales Representative
*
Select
Charlotte Korlolev
Harve Platig
Ismail Tmit
Panels For Testing
*
Infectious Disease
Tox
Blood
Antigen
Requisition
Mountain View Medical Laboratory
Non Reportable
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 :
Paper
Electronic
Preferred method of result notification :
Web Portal
HIPAA Fax #
EMR Direct
Add EMR Email
*
SalesRep Contact Info :
Primary Physician Details
Account Activation Type :
Email
Physician Email
*
(Associated with account login)
Password
*
Generate Password
Physician Full Name
*
NPI#
*
State License #
Primary Physician Signature
Add User
Special Requests
Specimen Pickup Information
UPS
FEDEX
Pickup Time Requested:
Monday
Tuesday
Wednesday
Thursday
Friday
Projected Specimens
PathDNA
CNS & Tick-Borne
X
Eye ENT
X
Gastro
X
Men's Health
X
Nail
X
RPP+
X
Respiratory
X
UTI
X
Women’s Health
X
Wound
X
CGX
CGX
X
PGX
Amplis
X
Toxicology
Oral
X
Urine
X
Blood
Blood Allergy
X
Blood Wellness
X
×
Please upload files
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Master Facility Portal
Master facility portal