Facility Set-Up Form
Client
*
Name
Client Site
Name
Does the facility share medical records with other client sites?
Yes
No
Is this client affiliated with another client?
*
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax
*
Please enter a valid fax number.
Format: (000) 000-0000.
Specialty
Addiction
Behavioral
Cardiology
Concierge
Dermatology
DPC
Gastro
Geriatric Care
Health Dept
Home Health
Hospice
Hospital
Internal Med.
LTC
MAT
OBGYN
Pain Mgmt.
PCP
Peds
Podiatry
Psychiatry
Telehealth
Urgent Care
Urology
Womens Health
Wound Care
Type of Testing
Molecular
Toxicology
PGx
Do you they take Workers Compensation?
Yes
No
Field Specialist Requested?
Yes
No
Screening Information with Toxicology:
Drug Screen In-Office (POCT)
Drug Screen at Lab (ILDP)
Provider Name and NPI
*
Ordering Provider Signature Email
For physician signature
Name & Email for LIMS (Results through Portal)
How do they want their results?
Portal
Email
Faxed
Client Billing / Skilled
Primary Contact for Client Billing Inquiries
Most Commonly Used for Skilled Nursing Facilities
Client Billing Contact Email
*
example@example.com
UPS Set-Up
Specimen Pick-Up
UPS Pick-Up
Lockbox Needed?
Please Select
Yes
No
UPS Pick-Up
Staying on current placard
Established UPS process currently in place
Placard Needed (Prearranged pickup times)
Main Contact
First Name
Last Name
Phone Number
Please enter main contact phone number.
Format: (000) 000-0000.
Email
Please enter main contact email.
Pick-Up Days and Times for PLACARD:
Please provide a 2-hour time frame alongside days of the week!
Sales Representative:
Any Additional Information?
Please contact
facilities@ildp.com
with any questions.
Submit
Should be Empty: