Draw Station Form

"*" indicates required fields

Account Demographics

Please fill all fields. Insert "N/A" if not applicable.

Practice Name*

Physician's Office Contact*

Phone*

Number of Locations*

Email*

Fax*

Number of Physicians*

Hours of Operation:

Mon*

Tues*

Wed*

Thurs*

Fri*

Sat*

Sun*

Physician Name / Nurse Practitioner, Credentials*

NPI# / EIN#*

Email for Portal*

Physician Name / Nurse Practitioner, Credentials

NPI# / EIN#

Email for Portal

Physician Name / Nurse Practitioner, Credentials

NPI# / EIN#

Email for Portal

Physician Address*

City*

State*

Zip*

Critical Value Contact*

Critical Value Phone*

Notes:

Payer Mix % :

BCBS*

United*

Humana*

Cigna*

Federal*

Aetna*

Other Comm*

Logistics Information

Clinic Start Date:*

Portal Training Date and Time:*

Account Management

Clinical Director: Denise Perez
Company: Anchor Lab Services, LLC

Sales Phone: 678-619-5555 ext. 107
Sales Email: DPerez@anchorls.com

Account Preference

Report Delivery Method:*

Fax

Web Portal

Critical Clinical Results

After Hours Phone*

Billing Information

Check all that apply:*

Commercial Insurance

Client Bill

Self Pay

Medicare

Medicaid

Estimated Monthly Volume:*

Physician Name*

Physician Signature**

Date*

Nurse Practitioner Name*

Nurse Practitioner Signature**