Provider Account Registration - Quality Forensic Toxicology

Signature Verification Affidavit

For all new accounts, we must receive confirmation of the ordering provider’s signature. Please have the ordering provider sign off and acknowledge their signature on a voided prescription order form or download the QFT Signature Verification Affidavit Document below.

Whichever option you utilize, you will upload these at the bottom of the Provider Account Registration before clicking “Submit.”

QFT Signature-Name-Affidavit Download

Date
Date Format: MM slash DD slash YYYY
Email
(of person submitting this form)
Account Rep
(QFT Rep Name)
Practice Information
Practice Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
Hours of Operation
Main Contact Name
First Last
Main Contact Phone
(If different than main #. Please indicate if this is a cell phone.)
Main Contact Email
Send Results via
- Fax
- Web Portal
- Fax & Web Portal
Specimen Handling & Shipping
Main Contact for Specimen Handling
Shipping Preference
- UPS
- LSO (where available)
- Local Courier
Provider Information
*
Please include appropriate credentials (i.e. M.D., D.O., PA, NP-C, etc). In order to add more than one provider, click the plus sign inside the circle to the right of the provider name box.
NPI Number Provider Name
Does the clinic intend to bill for presumptive screening?*
If yes is chosen = clinic will bill; QFT will not bill
If no is chosen = it is billable by QFT
- Yes
- No
- Sometimes
Additional Helpful Information
(If Needed)
Provider Signature Section
Physician Signature
Upload Your Provider Signature Page Here
Drop files here or
Before clicking on the submit button below, upload the QFT Signature Verification or a signature on a voided prescription order form.

If you have filled out a majority of the Provider Account Registration form, but do not have everything you need to complete it, you may click "save and continue later" below. It will allow you to save a link access for 30 days.
Email
This field is for validation purposes and should be left unchanged.

Save and Continue Later

NPI Number	Provider Name

Signature Verification Affidavit

Practice Information

Specimen Handling & Shipping

Provider Information

Provider Signature Section