Client Information and Physician Authorization

Fill out the Client Information and Physician Authorization Form below. A copy will be automatically sent to Qitek Labs.

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Client Information and Physician Authorization Form

Account Information
- Account Name*
- Phone*
- Fax
- Email*
- Address*
- City*
- State*
- Zip Code*
- Contact Name*
- Title*
- Hours*
Testing Services and Estimated Monthly Volume
- Toxicology
- Chemistry
- Carrier Screening
- Pharmacogenomics
- Cancer Genomics
- Familial Hypercholesterolemia
- Hematology
- Parkinson's/Alzheimer's/Dementia
- Molecular Micro (RPP/UTI/Wound)
Payer Mix
- % Medicare
- % Medicaid
- % PPO
- % HMO
- % Work Comp
- % Cash
Reporting Preferences (Preferred Method)
Option 1
- Fax to Clinic (Paper)
- Option 2
  - Web Reporting (Portal)
- Desired Username (8 alphanumeric characters)
- Desired Password
- Option 3
  - EMR Integration (*Special Conditions Apply)
- EMR
- Contact
- Phone
- E-mail
Shipping Information
- Preferred Provider*
  - UPS
- Daily Pick-Up Needed*
  - Yes
  - No
- Pick-Up Time Needed (HH:MM AM/PM)
- Location of Pick-Up
Electronic Order Entry Authorization
I hereby authorize the individual listed below to electronically access Qitek Lab's web portal and order tests at my discretion. I further authorize the individual identified below as "Site Administrator" to add and edit user access for our practice/facility.
Name*
Physician Signature Record
Please include all physician ordering tests. The individuals listed below are authorized to sign patient test requisitions (limited to MD, DO, DC, PA, or ARNP only). RN's are not authorized to sign test requisitions. The person(s) below understand and acknowledge that they will only order tests that they believe to be medically necessary to ensure patient compliance with the therapy that they have prescribed.
- Name 1*
- NPI # 1*
- Credentials (MD/DO/DC PA/ ARNP) 1*
- Signature 1*
- Date 1*
  Date Format: MM slash DD slash YYYY
- Direct Physician E-mail 1*
- Name 2
- NPI # 2
- Credentials (MD/DO/DC PA/ ARNP) 2
- Signature 2
- Date 2
  Date Format: MM slash DD slash YYYY
- Direct Physician E-mail 2
Sales Information
- Sales Representative*
- Phone*
- Email*
- Signature*
- Date*
  Date Format: MM slash DD slash YYYY
- Sales Group
- Sales Group Representative
- Signature
- Date
  Date Format: MM slash DD slash YYYY

Save and Continue Later

Fill out the Client Information and Physician Authorization Form below. A copy will be automatically sent to Qitek Labs.

Client Information and Physician Authorization Form

Account Information

Testing Services and Estimated Monthly Volume

Payer Mix

Reporting Preferences (Preferred Method)

Shipping Information

Electronic Order Entry Authorization

Physician Signature Record

Sales Information