Testing Program Onboarding & Service Authorization Form

Testing Program Onboarding & Service Authorization Form

Please complete this form to establish your testing coordination profile.
Organization Information
Legal Business or Practice Name
Organization Type
Primary Contact Name

First NameLast Name
Primary Contact Title
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Cities Where Testing Will Occur
Test Program Details
Which testing programs require coordination?

Other
Is this request part of an ongoing program or single case?
Testing Structure and Workflow
Estimated Monthly Testing Volume
Testing Frequency
What collection setup best fits your program?
Do you anticipate after hours or urgent coordination needs?
Clinical or Program Testing Structure
Which specific tests or specimen types will your program require?

Other
Do you require customized testing panels based on your organization or provider panels?
If yes, please list your desired panels.
Is confirmation testing typically required for non negative results?
Compliance and Documentation
Documentation Requirements
Have you previously experience issues with chain of custody, scheduling delays, or documentation accuracy?
Authorized Results Recipient

First NameLast Name
Title
Email
example@example.com
Only authorized recipients will receive testing results in accordance with applicable privacy and compliance standards.
Desired Service Start Date

MonthDayYear
Date
Are you the final decision maker for testing coordination services?
Decision Maker

First NameLast Name
Title
Client Acknowledgements and Consents
Client Acknowledgement & Consent

I understand that Great Expansion Enterprise LLC operates as a Medical Third-Party Administrator coordinating testing services through certified partner laboratories, mobile collectors, and collection sites. Specimen collection and laboratory analysis are performed by independent third party providers. Authorized recipients must be designated for result delivery, and electronic communication may be used for scheduling, coordination updates, and documentation. Final clinical decisions, employer policies, or legal determinations remain the responsibility of my organization or ordering party.
Electronic Communication Consent
Signature
Client Name

First NameLast Name
Title
Date

MonthDayYear
Date
Should be Empty:

Testing Program Onboarding & Service Authorization Form

Organization Information

Test Program Details

Testing Structure and Workflow

Clinical or Program Testing Structure

Compliance and Documentation

Client Acknowledgements and Consents