Please fill out the form below to request a connection with a lab
* = Required information
Information about your facility
*	Your Facility's Name
*	Address
*	City
*	State
*	Zip
*	Enter information about Providers with a valid NPI number who will request lab work	Last Name First Name MI Title NPI 1 2 3 4 5
*	Your Business Contact
*	Business Contact Phone#
	Business Contact Email
	Business Contact Fax#
	Your IT Contact
	IT Contact Phone#
	IT Contact Email
	IT Contact Fax#
*	Your EHR's Name
*	The EHR Company Name
*	Do you already place lab orders from this EHR?	Yes No
Information about the lab you wish to connect
*	Lab Name
	Lab Contact
	Lab Contact Phone#
	Lab Contact Email
	Does your facility have multiple locations?	Yes No
	Location Information and Account Management Will you want to track the locations of orders? Yes No    Do locations have their own lab Account#? Yes No    Enter location information: Location Name Location Account#
*	Do you already have an account with this lab?	Yes No
	If Yes, enter your account number
	Lab Type? (Select all that apply)	Clinical Micro Anat Path Imaging Molecular Toxicology Other
*	Approximately how many orders per week will go to this lab?
*	When will you be ready to start using this new connection?
*	Blood Draws are performed at (Select all that apply)	Inhouse Lab's PSC Other (Specify)
	Comment: Enter any special notes regarding this connection
We will begin processing your request immediately. You can expect to hear back within 7 - 21 business days.