New Client Registration Form

Register

Become a part of our provider network.

14340 Bolsa Chica Street, Suite D Westminster, CA 92683

(P) 949-229-0662 (F) 714-908-8668

CLIA #05D2261977
Client Information
Type of medical practice *
e.g. Internal Medicine, Plastic Surgery etc.
Facility Name *
Facility NPI*
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please select your days and hours of operation*

	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Open
Closed

Expected start date to begin services w/ Lions Lab*

MonthDayYear
Lions Representative*
Please enter your Lions Laboratory representative's full name.

Primary Contact Person

Please provide the information for your preferred administrative contact.
Title*
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Critical Results Contact

It is Lions' policy to document and inform our facilities of any test results that fall within our critical reference ranges.
Critical Results Contact Name*

First NameLast Name
Critical Results Contact Phone Number*
Please enter a valid phone number.

Ordering Providers

Please only list providers who will be ordering lab work.
Ordering Physician #1
Ordering Physician's Full Name*

First NameLast Name
Credentials: MD/NP/PA/DC*
NPI #*
Ordering Physician #2
Ordering Physician's Full Name

First NameLast Name
Credentials: MD/NP/PA/DC
NPI #
Ordering Physician #3
Ordering Physician's Full Name

First NameLast Name
Credentials: MD/NP/PA/DC
NPI #
Ordering Physician #4
Ordering Physician's Full Name

First NameLast Name
Credentials: MD/NP/PA/DC
NPI #

Provider Billing Information

At this time, we do not accept HMO's.
Select all types of patients you accept at your facility?*

Medi-CalMedicarePPOWe are cash only
If facility is cash only, please select who is the preferred party to bill for services.

Bill FacilityBill Patient via Credit Card Authorization Form
If insurance is not provided, please select who is the preferred party to bill for services.*

Bill FacilityBill Patient via Credit Card Authorization Form

Lab Orders

Please specify the tests that your physician orders for laboratory work, whether they are routine or occasional.
Provide a list of all tests most commonly ordered by your physician.*
Test Panels

If you wish to customize test panels, please list them below.
Panel 1
Name of Panel 1
Please specify the tests you wish to include in panel 1.
Panel 2
Name of Panel 2
Please specify the tests you wish to include in panel 2.
Panel 3

Phlebotomy Service Request

Lions Laboratory offers appointments and walk in blood draws at our Westminster location.
Is your facility interested in utilizing Lion's phlebotomy services?*

Yes, at our facility.Yes, at our patient's home or their desired location.We will refer our patients to your draw center in Westminster.No, we will collect specimens from our patients.N/A
Appointments and walk in blood draw location

14340 Bolsa Chica Rd. Suite F, Westminster, CA 92683

Monday - Friday 8am - 4:30pm

Saturday 8am-2pm

Sunday CLOSED

(P) 949-229-0662

(F) 714-908-8668

Provider Portal Information

After you submit the form, you will receive a 7-minute training video that will walk you through the provider portal. You will also receive a username, a temporary password, and the link to access it. Should you require an additional training session, please respond to the email that will be sent.
Name of the Person Who Will Receive the Training Video*

First NameLast Name
Email*
example@example.com
Phone number*
Please enter a valid phone number.
Patient Lab Results
What is your facility’s preferred way of receiving patient results?*

Lab Nexus Provider PortalFaxBOTH

Acknowledgement

Please review our terms and conditions
By checking these boxes below, I hereby acknowledge that I have completely read and fully understand Lions Laboratory Guidelines.*

1. I hereby acknowledge that Lions Laboratory will perform laboratory testing for patients from my facility as indicated on the requisition forms. In addition, Lions Laboratory kindly requests 7 days' notice for the discontinuation of laboratory services.2. By signing this form, it is hereby certified that the treating physician shall review the volume, frequency, and duration of testing and order laboratory testing accordingly and in accordance with clinical indication and medical necessity. I understand that it is my responsibility to determine the medical necessity of tests I have requested for the treatment and/or diagnosis of my patients. I agree to provide diagnosis codes, defined to the highest level of specificity, for each test that I order to confirm medical necessity and to enable Lions Laboratory to bill on my patient’s behalf.3. By signing this form, I acknowledge if any Point of Care (POC) device is provided by the lab I will not directly or indirectly bill a collection fee for POC testing without submitting payment to the lab for the device at a fair market value rate. I agree and understand the device will be used solely to collect, transport, process, or store specimens referred to the lab for testing. I acknowledge and understand that use of the POC device for any other purpose or billing for POC testing with laboratory-provided POC devices without remitting payment for same to the lab could be interpreted as a violation of Anti-Kickback Statue 42 U.S. C. § 1320a-7b.
I hereby acknowledge that Lions Laboratory will perform blood, urine and other specimen testing for patients from my facility as indicated on requisition forms.
Signature*

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Client Information

Primary Contact Person

Critical Results Contact

Ordering Providers

Provider Billing Information

Lab Orders

Test Panels

Estimated Number of Weekly Samples

Specimen Pick-up Details

Phlebotomy Service Request

Provider Portal Information

Patient Lab Results

Acknowledgement