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Email

This field is for validation purposes and should be left unchanged.

Contact Name*

First Last

Office Name*

Phone*

Fax

Email

Address*

Street Address City State ZIP Code

Best Time to Call

Office Information Details

Office Manager Name

First Last

Office Manager Phone Number

Lead MA Name

First Last

Lead MA Phone Number

Billing Contact Name

First Last

Billing Contact Phone Number

After-Hours Contact Name (Critical Results Calls)

First Last

After-Hours Contact Phone Number

Billing Type (check all that apply)

Client
Patient/Insurance

Patient Draw/Collection Location

In-House
Express Lab Patient Service Center

Report Delivery Method(s): (Check all that apply)

Fax
Email
Online Result Portal (LabNexus)

Courier Pickup Schedule

Pickup Type (check one):

Will-Call for Pickup
Routine Route Pickup

Standard Work Days

Monday
Tuesday
Wednesday
Thursday
Friday

Standard Opening Time

:

Standard Closing Time

:

Special Hours

Add any unique weekly hours that differ from the above standard opening and closing time (ie closed for lunch between 12:30pm and 1:00pm daily).

Physician Information

Physician Name (1)

First Last Specialty/Credentials NPI#

Online Result Portal Access

Yes
No

Physician Name (2)

First Last Specialty/Credentials NPI#

Online Result Portal Access

Yes
No

Physician Name (3)

First Last Specialty/Credentials NPI#

Online Result Portal Access

Yes
No

EMR Interface Request

An Express Lab Rep will follow-up to discuss and approve.

EMR Name

EMR Account Rep Name

First Last

EMR Account Rep Phone

EMR Account Rep email

Office Contact / IT Contact Name

First Last

Office Contact / IT Contact Phone

Office Contact / IT Contact Email

Anticipated Start Date

Notes

Enter any other details or information.

PHYSICIAN SIGN-UP

New Physician Account Sign-Up

Online Physician Sign-up Form

Office Information Details

Courier Pickup Schedule

Physician Information

EMR Interface Request