Name of Facility (required)
Facility Phone Number (required)
Facility Fax Number (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)
Customer Rep (required) —Please choose an option— Peter Gudaitis Kelly Condon Steven Penalver Thomas Bejgrowicz Tiffany Horne
Medical Director
MD NPI #
IT Department Contact - Name (required)
IT Department Contact - Title (required)
IT Department Contact - Phone (required)
IT Department Contact - Email (required)
Facility WiFi SSID (required)
Facility WiFi Password (required)
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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)
Asst. Director of Nursing - Name (required)
Asst. Director of Nursing - Title (required)
Asst. Director of Nursing - Phone (required)
Asst. Director of Nursing - Email (required)
Staff Educator - Name (required)
Staff Educator - Title (required)
Staff Educator - Phone (required)
Staff Educator - Email (required)
Infection Control - Name (required)
Infection Control - Title (required)
Infection Control - Phone (required)
Infection Control - Email (required)
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To support accurate billing and avoid delays, Aculabs will often require admission facesheets, containing patient demographic and insurance information. Please provide the standard contact person for this process.
Name of Facesheets Contact (required)
Facesheets Contact - Title (required)
Facesheets Contact - Number (required)
Facesheets Contact - Email (required)
Aculabs may inquire about being granted access to your EMR system only for the purpose of retrieving specific reports containing admission records and daily or monthly census information.
Can we have access to your EMR system? (required) Yes No
Do you have Part A Days? (required) Yes No
Do you HMO Days? (required) Yes No
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Please list your facility's units, room numbers associated with each unit, and fax number for each unit. Note: If your facility offers various levels of care, and the level of care offered is not stated in the names of each unit, please specifically note below what level of care each specific unit offers (ie: skilled nursing, assisted living, independent living, etc.) (required)
Please list location of all specimen refrigerators (aka where collected urine or stool samples are stored) in the building, noting unit placement and if the fridge requires any special access in order to be reached. (required)
Please list any special instructions our mobile phlebotomists might have to follow when accessing or entering your building or campus (ie: if the technician must park in a specific parking lot, if specific entrances are locked during certain hours, if a specific employee entrance is preferred. (required)
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Aculabs accepts ACH payments. Please provide the contact person responsible for setting up ACH payments.
Name of ACH Payment Contact (required)
ACH Payment Contact - Title (required)
ACH Payment Contact - Number (required)
ACH Payment Contact - Email (required)
As part of Aculabs’ start-up process, we may need to perform a credit check. Please provide the contact person authorized to complete the credit check form. Please ensure that you provide their direct phone number in the field below.
Name of Credit Check Contact (required)
Credit Check Contact - Title (required)
Credit Check Contact - Number (required)
Credit Check Contact - Email (required)
New invoices can be sent to a designated contact person. Please provide the contact details for this desired designation. Should invoices be sent to your facility or to a third-party billing company? (required) Facility/Corporate Contact Third-Party Billing Contact
Name of Invoice Contact (required)
Invoice Contact - Title (required)
Invoice Contact - Number (required)
Invoice Contact - Email (required)
If your facility currently utilize standing orders (aka reoccurring orders), will you be able to provide a trash-run of your current reoccurring orders?Yes No
Notice: It is vitally important that the standing orders indicate the months the orders are to be drawn. If the list of standing orders does not include dates, it will be necessary to ascertain the dates or make a decision on what dates you wish us to input all of your reoccurring orders. It will be important to make sure the laboratory orders we receive coincide with your physician’s orders.
Please ensure your file is in .pdf, .doc, or .docx format and under 5MBs in size.
To help assist us as much as possible, please be aware that you'll need to assemble a listing of information you have on relevant physicians. This listing should include physicians' names, addresses, phone numbers, fax numbers, and NPI numbers. You may submit it as an attached document for convenience.
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