P23 LABS NEW ACCOUNT SETUP FORM-Wholesale/Client Bill or Traditional
Type of Account Requested
Client Bill
Wholesale
Distributor
Insurance Billing
Account Set-up Information
Anticipated Start Date
-
Month
-
Day
Year
Date
ANTICIPATED MONTHLY VOLUME:
MOLECULAR/PCR
COVID-19 (Antibody and/or PCR)
PGX
CLIENT WILL BE UTILIZING E-REQUISITION
NAME AND BEST PHONE NUMBER FOR CONTACT AT CLIENT FOR MEDICAL RECORDS, AND SUPPORTING DOCUMENTATION FOR PRIOR AUTHORIZATION:
NAME
Name
First Name
Last Name
PHONE NUMBER
Phone Number
-
Area Code
Phone Number
EMAIL ADDRESS
Email
example@example.com
PRACTICE/FACILITY NAME
MAIN CONTACT NAME
ADDRESS
CITY
STATE
ZIPCODE
CONTACT FOR TEST ORDER QUESTIONS
PROVIDER INFORMATION (IF CLIENT BILL ACCOUNT, PLEASE LEAVE BLANK)
PROVIDER NAME
EMAIL
example@example.com
NPI NUMBER
STATE LICENSE NUMBER
Signature
RESULT DELIVERY OPTIONS
Report Delivery Preference
Fax Reports
Web Reporting
Email Reports
HL7 or API Interface
PICK UP INFORMATION
DAILY PICKUP(UPS PREFERRED):
START DATE
ANTICIPATED START DATE
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