New Client Form "*" indicates required fields Account DemographicsPlease fill all fields. Insert "N/A" if not applicable.Practice Name* Clinic 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 Clinic Address* City* State* Zip* Critical Value Contact* Critical Value Phone* Notes: Payer Mix % :BCBS* United* Humana* Cigna* Federal* Aetna* Other Comm* Logistics InformationClinic Start Date:* Training Date and Time:* Fedex Pick up:(days/time)Mon* Tues* Wed* Thurs* Fri* Sat* Sun* Initial Supply Order: (check all that apply) Initial collection supplies Requisition forms Anchor draw patient handouts Phlebotomist Needs: (check one) Will send patients to draw center Collection in clinic Will collect in clinic and send to draw site Account ManagementClinical Director: Denise PerezCompany: Anchor Lab Services, LLCSales Phone: 678-619-5555 ext. 107Sales Email: DPerez@anchorls.comAccount PreferenceReport Delivery Method:* Fax Web Portal Hard Copy EMR Integration EMR Interface Request: EMR name EMR Contact/Phone Hardware Request:* High Speed Line Remote Printer Computer Label Printer Critical/Malignancy Calls:* Critical Clinical Results Malignancy After Hours PhoneSupply Request COVID Toxicology/UTI Genetic Swabs Pathology/Blood Allergy Respiratory Billing InformationClick all that apply* Commercial Insurance Client Bill Clinical Medicare/Medicaid Estimated Monthly Volume:* Physician Name* Physician Signature** Date* Nurse Practitioner Name* Nurse Practitioner Signature** Date* *DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
