New Account Form

New Account Form

* PHYSICIAN/GROUP NAME:

* NAME OF PHYSICIAN #1:

* LAB ASSIGNED ACCT#:

* UPIN #:

* STREET ADDRESS:

* NPI #:

* CITY:

* MEDICAL SPECIALTY:

* STATE/PROVINCE:

NAME OF PHYSICIAN #2:

* COUNTRY:

UPIN #:

* ZIP/POSTAL CODE:

NPI #:

* PHONE: (include area code)

MEDICAL SPECIALTY:

FAX:

NAME OF PHYSICIAN #3:

* EMAIL ADDRESS:

UPIN #:

TYPE OF SPECIMEN BEING SENT

FREQUENCY:

Complete Reading/Diagnosis:

Day

Week

Month

Consultation with Prepared
Slide OPD Slide Preparation:

Day

Week

Month

X Required # of
Slide(s) / Each Block:

Day

Week

Month

NPI #:

MEDICAL SPECIALTY:

CONTACT PERSON:

OFFICE HOURS:

Mon

Tues

Weds

Thurs

Fri

TYPE OF BILLING - check as many as apply

PRIVATE INSURANCE

PATIENT

PHYSICIAN

PRIVATE MEDICINE

ORAL AND MAXILLOFACIAL PATHOLOGY

PATIENT BILLING ONLY

COMMENTS: