COVID-19 Testing Startup

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Please be aware that a pop-up will appear upon successful submission before being redirected back home.

Notice: To expedite the process for COVID-19 testing, Aculabs has set up the below form for facilities to fill out in order to make the onboarding process even easier. Further questions about using Aculabs for COVID-19 testing can be sent to info@aculabs.com.

Please ensure that all files are properly compressed and appropriately encrypted before sending.

1
Facility Info
2
Staff Info
3
Unit Info
4
Billing Info
5
Courier Info

1/5

Facility Info

Name of Facility (required)

Address Line 1 (required)

Line 2

City (required)

State (required)

Zip Code (required)

Your Name (required)

Your Email (required)

Corporation Name [or Privately Owned] (required)

Medical Director (required)

MD NPI # (required)

Customer Rep (required)

Administrator - Name (required)

Administrator - Title (required)

Administrator - Phone (required)

Administrator - Email (required)

Director of Nursing - Name (required)

Director of Nursing - Title (required)

Director of Nursing - Phone (required)

Director of Nursing - Email (required)

Business Office Contact - Name (required)

Business Office Contact - Title (required)

Business Office Contact - Phone (required)

Business Office Contact - Email (required)

IT Department Contact - Name (required)

IT Department Contact - Title (required)

IT Department Contact - Phone (required)

IT Department Contact - Email (required)

25%

Facility Phone Number (required)

Facility Fax Number (required)

Would you like your results faxed to this number?:(required)
YesNo

Please list your facility's units, room numbers associated with each unit, and fax number for each unit. (required)

Please list the location of all specimen refrigerators in the building, noting their unit and placement. (required)

50%

Name of Facesheets Contact (required)

Facesheets Contact - Title (required)

Facesheets Contact - Number (required)

Facesheets Contact - Email (required)

Name of Invoice Contact (required)

Invoice Contact - Title (required)

Invoice Contact - Number (required)

Invoice Contact - Email (required)

Name of Accounts Payable Contact (required)

AP Contact - Title (required)

AP Contact - Number (required)

AP Contact - Email (required)

Name of Daily Census Contact (required)

Daily Census Contact - Title (required)

Daily Census Contact - Number (required)

Daily Census Contact - Email (required)

Monthend Census Contact (required)

Mothend Census Contact - Title (required)

Monthend Census Contact - Number (required)

Monthend Census Contact - Email (required)

75%

Aculabs Specimen Box Location: (required)

Special Pick-Up Instructions:

If specimen box is located inside, does building ever lock?:(required)
YesNo

100%