Lab Testing Onboarding Form

Lab Testing Onboarding Form
Urine ToxBloodCovid/RPPPGXWoundUTIOther
Today's Date*
Account Start Date (if different)
Name*

First NameLast Name
Your Practice's Name*
Practice's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Standard ClinicVirtual ClinicVirtual & In-Person ClinicMobile PhlebotomyConcierge ClinicOther
Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Business Email*
example@example.com
HIPPA Fax # (if available)
Please enter a valid phone number.Format: (000) 000-0000.
PROJECTED VOLUME
For the applicable tests, complete the monthly projected volume *
CONTACTS
LAB REPORT CONTACT *
24hr CriticalRejections/CollectionsOffice Manager
24hr Critical Contact*
Rejections/Collections Contact*
Office Manager Contact*
PROVIDER INFORMATION
Main Provider*
PROVIDER SIGNATURE *

Clear
PLEASE ENSURE THIS SIGNATURE IS HANDWRITTEN, NOT A DIGITAL FONT SIGNATURE
LAB RESULTS REQUEST
Via Hippa Compliant FaxVia Portal Access (login will be sent to you post signup)
Portal Accesser*
Name of Person Granted Access To Portal
Email For Portal Access & Alerts*
example@example.com
SHIPPING REQUESTS
via FedExvia UPSNo preference
Drop at FedExFedEx Pickup at locationDrop at UPSUPS Pickup at locationNo preference
Morning (9am-noon)Mid-Day (noon-3pm)Afternoon (3pm-5pm)
MondaysTuesdaysWednesdaysThursdaysFridaysSaturdaysSundays
Morning (9am-noon)Mid-Day (noon-3pm)Afternoon (3pm-5pm)On Demand As Tests Occur
Should be Empty:

PROJECTED VOLUME