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 #
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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)
Facility WiFi SSID (required)
Facility WiFi Password (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. 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)
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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)
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
[group group-emrtype]
Name of EMR Contact (required)
EMR Contact - Title (required)
EMR Contact - Number (required)
EMR Contact - Email (required)
Your EMR System (required) PointClickCare SigmaCare Other
If "other", please specify what EMR system you use (required)
Do you have Part A Days? (required) Yes No
Do you HMO Days? (required) Yes No
[group group-census]
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)
[/group]
Do you have AL and/or IL beds? (required) Yes No
[group group-alil]Previous Next
Please list any special instructions our mobile phlebotomists might have to follow when accessing or entering your building or campus. Ex: 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)
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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