PSC Walk-In Account Setup- Mako Medical

PSC Walk-In Account Setup- Mako Medical

PSC Walk-In Account Setup
Provider Name:

First NameLast Name
Provider NPI:
This is always a 10 digit number
Account Details
Clinic Name:
Clinic Address

Account Contact Information
Primary Contact Name:

First NameLast Name
Primary Contact Email:
Clinic Phone Number:
Format: (000) 000-0000.
Clinic Phone Extension
Clinic Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Billing Contact Name:

First NameLast Name
Clinic Billing Contact Number:
Format: (000) 000-0000.
Billing Contact Phone Extension:
Billing Contact Email:
Billing Fax Number:
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Billing Contact Method:

Clinical Contact Information
Please note the appropriate persons to serve as a contact for laboratory staff to relay clinical information, including critical values.
Primary Clinical/Critical Contact Full Name:

First NameLast Name
Clinic Contact Phone Number:
Format: (000) 000-0000.
Covid-19 Reporting
Should COVID-19 results be auto-released or first called to a provider?
Should be Empty: