New Account Form

Client Status

New Client
Revision

Account Type

Global
TC/PC

Start Date

Submitting Representative

Physical Office Name

Ordering Physician #1

NPI #1

Ordering Physician #2

NPI #2

Ordering Physician #3

NPI #3

Ordering Physician #4

NPI #4

Address

Address Line 1

City

State

Zip Code

Phone

Private/Backline

Main Fax

Contact #1

Name *

Title

Phone

Fax

Email *

Contact #2

Name *

Title

Phone

Fax

Email *

Additional Contacts

After Hours Contact Name

After Hours Contact Number

IT Issue Contact Name

IT Issue Contact Number

Specimen Pickup Contact Name

Specimen Pickup Contact Number

Comments/Special Handling Instructions

GLOBAL Anticipated Cases Per Month

Expected Turnaround Time (in Days)

Please add 1 day for Fedex/UPS each way

TC/PC Anticipated Cases Per Month

Expected Turnaround Time (in Days)

Please add 1 day for Fedex/UPS each way

Courier and Shipping Instructions

Where should the biopsies be picked up?

Office
Surgery Center
Other

If surgery center or other is checked, provide address and hours below

Surgery Center/Facility Name *

Address

Address Line 1

City

State

Zip Code

Main Phone

Fax

Private/Backline

Desired preference of specimen pick up?

UPS
FedEx
Courier
No Preference

Preferred Pick Up Schedule (Courier/UPS/FedEx) at Surgical Center?

Mondays

Between

And

Building Closes At:

Tuesdays

Between

And

Building Closes At:

Wednesdays

Between

And

Building Closes At:

Thursdays

Between

And

Building Closes At:

Fridays

Between

And

Building Closes At:

Saturdays

Between

And

Building Closes At:

Will specimens be left in box after hours?

Is Box accessible to courier after business hours?

Box Location

Preferred Pick Up Schedule (Courier/UPS/FedEx) at Office?

Mondays

Between

And

Building Closes At:

Tuesdays

Between

And

Building Closes At:

Wednesday

Between

And

Building Closes At:

Thursday

Between

And

Building Closes At:

Fridays

Between

And

Building Closes At:

Saturdays

Between

And

Building Closes At:

Will specimens be left in box after hours?

Is Box accessible to courier after business hours

Box Location

Preferred Delivery Schedule (Courier/UPS/FedEx) at Surgical Center?

Mondays

Between

And

Building Closes At:

Tuesdays

Between

And

Building Closes At:

Wednesdays

Between

And

Building Closes At:

Thursdays

Between

And

Building Closes At:

Fridays

Between

And

Building Closes At:

Saturdays

Between

And

Building Closes At:

Can reports be left in box after hours?

Is Box accessible to courier after business hours?

Box Location

Preferred Delivery Schedule (Courier/UPS/FedEx) at Office?

Mondays

Between

And

Building Closes At:

Tuesdays

Between

And

Building Closes At:

Wednesdays

Between

And

Building Closes At:

Thursdays

Between

And

Building Closes At:

Fridays

Between

And

Building Closes At:

Saturdays

Between

And

Building Closes At:

Can repots be left in box after hours?

Is Box accessible to courier after business hours?

Box Location

Reporting and Technology

Results reporting to be sent via:

Email
UPS/FedEx
Courier
Regular Mail

AutoFax to Office

Prelim - TCPC
Final - TCPC
Prelim - Global
Final - Global

AutoFax to Surgery Center

Prelim - TCPC
Final - TCPC
Prelim - Global
Final - Global

Comments

Dedicated Printer At Office

Prelim - TCPC
Final - TCPC
Prelim - Global
Final - Global

Dedicated Printer At Surgery Center

Prelim - TCPC
Final - TCPC
Prelim - Global
Final - Global

Comments

Daily Query

Query FAXED to OFFICE?

Fax #

Attention

Query FAXED to Surgical Center?

Fax #

Attention

Query EMAILED to OFFICE?

Comments

Query EMAILED to Surgical Center?

Comments

Is the client informed they can print reports via websites?

If reporting will be delayed due to special stain requests, how would you like to be contacted?

Phone @

Fax @

Email @

Do they have a printer in their office we can utilize for reporting?

Do they have an EHR?

Name

Is it HL7 compliant?

Are they expecting a reporting interface?

Is their PM system HL7 compliant?

Name

Are they expecting a reporting interface?

Supplies Needed

Formalin Cups 20ml

Checkboxes

Auto-Ship

Formalin Cups 40ml

Checkboxes

Auto-Ship

Formalin Cups 60ml

Checkboxes

Auto-Ship

Specimen Trap 40ml

Checkboxes

Auto-Ship

Sterile Urine Cups

Checkboxes

Auto-Ship

Biohazard Bag 6x9

Checkboxes

Auto-Ship

Biohazard Bag 12x15

Checkboxes

Auto-Ship

Prostate Kits

Checkboxes

Auto-Ship

Prostate Kits with Cassettes

Checkboxes

Auto-Ship

CytoLyt Cup 50ml

Checkboxes

Auto-Ship

CytoLyt Cup 80ml

Checkboxes

Auto-Ship

Comprehensive GI Kit

Checkboxes

Auto-Ship

Comprehensive Respiratory Kit

Checkboxes

Auto-Ship

Requisition Forms

Checkboxes

Auto-Ship

Other/Special Request

Ship Supplies to

Office
Surgery Center
Other

If Other please specify

Does the client need a specimen lock box?

Lock Box Size

Reporting Preference Check List

Microscopic descriptions
Microscopic images on reports
Malignant diagnoses in RED
Preliminary Report on delayed cases (to be followed by revised final report when case is completed)
Delayed report notice for pending case with additional studies/consultation
Specifically mention all “rule out” diagnoses on final report. ie – hx says rule out colitis, report says “no evidence of colitis”

Other Preferences/ Additional Notes for this Account