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)
Anticipated Start Date (per your CSR) (required)
Medical Director
MD NPI #
Customer Rep (required) --- Jeanette Santiago Kelly Clark-Condon Lucy Pellicane Peter Gudaitis Steven Penalver Thomas Bejgrowicxz Tiffany Horne
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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)
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)
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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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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)
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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)
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
Do you have AL and/or IL beds? (required) Yes No
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Do you have standing 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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