NEW ACCOUNT INFO SHEET Account Executive*Sign Up Date* Date Format: MM slash DD slash YYYY Account InformationPractice Name*Address Street Address Suite # City State ZIP Phone*Fax*Days* Select All Monday Tuesday Wednesday Thursday Friday Saturday Sunday Business Hours*Does this office have an in-house lab?* Yes No LogisticsSpecimen Transport*Shipment (FedEx)Courier (Pick up)Mobile Phlebotomist (Drop off)Is FedEx currently being used?*YesNoinside contact for FedEx PickupPhoneKey ContactsCollector (in office)Email CellLab ManagerEmail CellOffice ManagerEmail CellBilling ManagerEmail CellCritical Values ContactContact NameCellAfter Hours Contact*YesNoPhlebotomy Needed (subject to approval)Select*Hire phlebotomist from previous labRecruit a new phlebotomistOffice will provide a phlebotomistNew mobile phlebotomistExisting mobile phlebotomistNo phlebotomist neededPlease Provide details below if you select any option other than "no phlebotomist needed"Part time or Full time? Part Time Full Time Days Select All Monday Tuesday Wednesday Thursday Friday Saturday Sunday Hours NeededHow many phlebotomists are needed? One Two NameEmail CellNameEmail CellDesired Hourly Pay*CommentsMobile Phlebotomist (if applicable)NameMobile phoneCompany nameOffice phoneAddress Street Address City State Zipcode Email SelectNo supplies neededSupplies neededDraw FeeNotesBilling MethodMedicare Insurance Percentage*-- Select --0%10%20%30%40%50%60%70%80%90%100%Commercial Insurance Percentage*-- Select --0%10%20%30%40%50%60%70%80%90%100%Client Bill Percentage*-- Select --0%10%20%30%40%50%60%70%80%90%100%Daily VolumeAttach Signed Client PricingAttach Current UtilizationAttach Competitor PricingAttach Custom PanelsProvider InformationNameNPITitle--- Please select ---MDDOPANPRNNDEmail: NameNPITitle--- Please select ---MDDOPANPRNNDEmail NameNPITitle--- Please select ---MDDOPANPRNNDEmail NameNPITitle--- Please select ---MDDOPANPRNNDEmail NameNPITitle--- Please select ---MDDOPANPRNNDEmail: NameNPITitle--- Please select ---MDDOPANPRNNDEmail Supplies & EquipmentChoose Supplies & Equipment: (Select all that is needed)* Req. forms Centrifuge Printer Basic supply kit Other supplies Computer Phleb. Chair Label printer Shipping supplies Special requestsOrdering/Reporting MethodsSelect all that apply* Requisition forms Portal EMR (Subject to approval) Resulting MethodOrdering method (Need to select more than one item)* Fax Portal Encrypted email EMR (Subject to approval) Electronic Medical Recording System (subject to approval) *All new accounts will have access to portal EMR nameIT contactWill interface be required prior to starting?*YesNoClient Projected Start date Date Format: MM slash DD slash YYYY Has the client confirmed sign up?*YesNoUntitled
