Client Information and Physician Authorization

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Account Information
- Account Name*
- Phone*
- Fax
- Email*
- Address*
- City*
- State*
- Zip Code*
- Contact Name*
- Title*
Testing Services and Estimated Monthly Volume
- Toxicology
- Pharmacogenomics
- Molecular Micro (RPP/EAR/UTI/STI/Wound)
Payer Mix
- % Medicare
- % Medicaid
- % Commercial
Reporting Preferences (Preferred Method)
- Option 1
  - Fax to Clinic (Paper)
- Option 2
  - Fax to EMR
- Option 3
  - Web Reporting (Portal)
Shipping Information
- 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*
  MM slash DD slash YYYY
- Direct Physician E-mail 1*
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Account Information