Required fields designated with ** . The more information that you can provide on this form, the fewer questions our Sales/Service Team will have in creating your account.
Your Information:
Your Name: **
Your Phone Number (xxx) xxx-xxxx: **
Your Email Address:
Account Information:
Account Name:**
Full Address:**
Account Phone (xxx) xxx-xxxx:**
Account Fax (xxx) xxx-xxxx:**
Office Hours:**
Call After Hours Critical Results (xxx) xxx-xxxx:
Office Contact:
Account Details:
Billing Type: CLS to Bill the Patient's Insurance CLS to Bill Your Office
Supplies Needed: Centrifuge Specimen Collection Supplies Lock Box Paper Test Requisitons
Report Delivery: Courier Faxed Online (Requires a PC with Internet access and a quality printer.)
Physicians: Required Information: Last Name , First Name, Title | State License # | UPIN | NPI | Tax ID #
one per line please Example: MOUSE, MICKEY, MD | ME230039 | G23321 | 9909909909 | 59-9909909
Comments or Other Changes:
