PHYSICIAN SIGN-UP

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

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.

Phone

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

PHYSICIAN SIGN-UP

New Physician Account Sign-Up

Online Physician Sign-up Form

Office Information Details

Courier Pickup Schedule

Physician Information

EMR Interface Request