• Precision Point Diagnostics - Clinic Account Agreement Form

  • Please complete all required fields below. (Note: Precision Point Diagnostics does NOT accept business from New York State.)

  • Clinic Information

  • Format: (000) 000-0000.
  • Industry (select one)*
  • How did you hear about us?*

  • Primary Contact Information

  • This contact will be given full admin access to your portal and will be the primary point of contact for your account. Admin privileges allow this contact to create users and administer privileges within your portal. All communications regarding billing will be sent to this contact.
  • Format: (000) 000-0000.
  • Do you consent to text message communication?*

  • Primary Physician Details

  • Format: (000) 000-0000.
  • Do you consent to text message communication?*

  • Additional Ordering Physicians (if applicable):

  • Projected Specimens (Choose at least one from the categories below)

  • Allergy & Sensitivity
  • Medical Wellness
  • Endocrine
  • Gastrointestinal

  • Billing Preferences

    Note - The clinic may select multiple payment options or restrict the accounts payable to only one option, however each clinic will be required to keep a credit card on file if Clinician pay is selected. Please select all applicable billing preferences below. If you choose to change the methods of payment in the future, you must submit a Precision Point Diagnostics Revisions & Updates form
  • Billing Preference*

  • Newsletter Subscription

  • Other Terms & Conditions

    1. Checks will deposited immediately.
    2. Results are considered released upon upload to the Precision Point Diagnostics Clinician Portal.
    3. Any clinics choosing Clinician Pay option will be invoiced at least twice monthly, unless other arrangements have been agreed upon. All invoices are due within 7 days of the invoice date. Any payments received after the 7-day period are considered late.
    4. Any late payments, returned checks or declined credit cards will incur a 15% or $35 late payment penalty (whichever is greater). Any negotiated discounts may be permanently suspended due to late payment.
    5. Lack of payment in a timely manner will cause a hold to be placed on the account, and new samples will not be queued into production after notification of the "Client Hold" status. In addition, access to the Client Portal will be closed and not reopened until full payment and penalty fees are received.
    6. Failure to pay balances in a timely manner, or failure to honor payment arrangements may result in the account being turned over to collections.
    7. A test requisition, signed by a Provider and patient, and completed accurately is required for samples to be processed. Each Test Requisition represents a legal contract between the Clinician or Clinic. Precision Point Diagnostics, at its sole discretion, will process the Test Requisition as sent until such time as the Clinic updates or amends the Test Requisition.
    8. To make any changes to your account, a Revisions & Updates form must be completed. Note, testing may be delayed if the most up-to-date information is not on file.

  • ORDERING PROVIDER AGREEMENT By signing the electronic signature for the Clinic Account agreement, I indicate that all information is correct and I agree to be added to the Precision Point newsletter for e-mail updates from the laboratory. Also, I acknowledge that only licensed healthcare professionals may order laboratory testing for others, and it is my responsibility to abide by any local, state or federal laws that regulate ordering tests for others.

    PROMPT PAY AGREEMENT By signing the electronic signature for the Clinic Account agreement, I indicate that all information is correct. Also, I understand my specific responsibilities in the payment method chosen. If CLINICIAN PAY is selected above, I agree to be financially responsible for payment of all charges associated with this account.

  • Signature

  • Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
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