new facility_test - Industry Lab Diagnostic Partners

Client Name*

Is this client affiliated with another client?*

Yes

Client Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Fax*

Key Contact

Key Contact Name*

Title*

Email*

Direct Line*

Physician/Provider Name & NPI

	Name & NPI	Actions

There are no Entries.

LIMS Users

First/Last Name	Email Address	Actions

There are no Entries.

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Type of Account*

Type of Specialist*

Type of Testing*

Check all that apply.

Molecular

Toxicology

Volume Of Testing (Per Week)

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UTI Testing:*

UTI*

Toxicology*

Screening Information*

Drug screen in office (POCT)

Drug screen at lab (ILDP)

Frequency Per Patient*

Facility / Group EIN*

EHR Credentials

EHR Username:	Password:	EHR URL:	Actions

There are no Entries.

Billing Contact

FIRST/LAST NAME	Phone	Email	Actions

There are no Entries.

Must be different from the user.

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EHR Username*

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EHR Password*

This field is hidden when viewing the form

EHR URL*

This field is hidden when viewing the form

Payor Mix*

Insurance Of Patient Population

Medicare %*

Medicaid %*

List Top 2 Medicaid Insurances*

Commercial %*

List Top 2 Commercial Insurances*

Field Specialist Requested?*

Yes

Estimated # of days and times needed*

Shipping*

Courier Route

FedEx Pick Up /UPS Pick Up

Do you need a lock box?**

Yes

Facility Name*

Facility Address

Street Address Address Line 2 City State ZIP Code

Point Of Contact*

(First Name, Last Name)

Start Date of Pick Ups

Very Important! If you are requesting FedEx / UPS pick up then after you complete this form please complete the form below titled “FedEx/UPS Pick Up Request”. Your request will not be complete until you submit this additional form.

Additional Info

Sales rep*

Start Date*

Please contact facilities@ildp.com with any questions.

Facility Set Up Form

Key Contact

Volume Of Testing (Per Week)

Insurance Of Patient Population

Test Form