New Client Information for Build – With Contract

This form is for lab clients who will need a lab contract in place. If you have any questions, please contact your lab services account manager, Denise or Kara.

*Indicates required information

    Preferred Start Date*:

    Your Name*:

    Office Information:

    Office Legal Name*:

    Doing Business As (DBA Name)*:

    Office Address*:

    Suite Number:

    City*:

    State*:

    Zip*:

    County*:

    Office Phone Number*:

    Office SECURE Fax Number*:

    Facility type*:

    Specialty:

    Do you have other locations that send to or wish to send to Spectrum Health Laboratory? If Yes please provide a list of account names and addresses:

    Operations: Calling Critical Lab Values

    The following information is needed for our Laboratory Call Center. Critical Lab Values are called to a provider within 30 minutes of verification of test result. This is an accreditation requirement. We cannot accommodate physician schedule lists. These phone numbers will not be used for any calls besides critical lab values.



    Back Line Office Phone Number:

    After Hours Critical Phone Number*:

    Critical Phone Instructions*:

    Operations: Courier Services

    If your location needs courier services to pick up specimens collected in the office, please fill out the following. If not needed, please disregard this section. Note: Courier Services may not be available in all areas, we will try to accommodate your office's needs.

    Hours of Office Operations:

    Unlocked Building Hours:

    Pick up type:
    Routine-Your staff will only need to call for STAT pick-ups, any other pickups will be scheduled automaticallyOn Call-Your staff will need to call for ALL pick-ups
    Best Courier Pick Up Times (not actual, our Courier Services staff will find a time that works for your staff and our staff):

    What type of specimens will you be collecting in the office?

    Will you be sending patients to a Spectrum Health Draw Site?

    Lockbox type owned or needed:
    floor modelhanging model
    I have a Spectrum Health labeled Lockbox on location and it is located here:

    Operations: Supplies
    For general supplies, please fill out a Laboratory Supply Requisition give to you by your account manager.
    Our office will need a centrifuge
    Daily collection volume if centrifuge is needed:

    Operations: Information Services

    I am interesting in ordering and reviewing results through Spectrum Health's Online Portal (EpicCare Link)I am interested in using Spectrum Health's version of Epic as my EMR (Epic Community Connect)I am interesting in setting up an interface with my EMR and Spectrum Health's Epic (eSHare EMR Interface)I am currently not interested in electronic ordering and results (fax results)
    EMR Vendor Name
    I would like results delivered FaxedElectronic
    Note: A separate contract may be needed for Information Services for electronic access to patient records.

    Operations: Billing
    Spectrum Health Laboratory Billing is performed by the Hospital Billing Team. Patients may seek assistance through the Financial Services office. Billing questions should be directed to the phone number on the patient's bill. Additional billing may be sent from our contracted Pathologists "Michigan Pathology Specialists"

    Yes Ordered Lab Work will be billed to Patient or Patient's Insurance (3rd party billing/patient bill)Yes, Lab Work may also be billed to this office or facility (client bill)

    For client billing, a contract will be needed prior to go-live. Contract work may take up to 4 weeks or more.

    Contacts

    Office Manager First and Last Name*:

    Office Manager Email*:

    Office Manager Phone Number*:

    Sign up to receive Laboratory News via email? yes

    Legal Contact*:

    Legal Email*:

    Legal Phone Number*:

    Contract Contact 1*:

    Contract Email*:

    Contract Phone Number*:

    Contract Noticee type? BillingLegal

    Contract Contact 2*:

    Contract Email*:

    Contract Phone Number*:

    Contract Noticee type? BillingLegal

    Contract Contact 3:

    Contract Email:

    Contract Phone Number:

    Contract Noticee type? BillingLegal

    Provider First and Last Name*:

    Provider Email:

    Provider NPI*:

    Sign up to receive Laboratory News via email? yes

    Provider First and Last Name:

    Provider Email:

    Provider NPI:

    Sign up to receive Laboratory News via email? yes

    Provider First and Last Name:

    Provider Email:

    Provider NPI:

    Sign up to receive Laboratory News via email? yes

    Provider First and Last Name:

    Provider Email:

    Provider NPI:

    Sign up to receive Laboratory News via email? yes

    Additional Providers and Contacts. Please include full name, email, phone and role.

    Additional Information or Comments

    Note: Please do not use this online form to send health information about a patient, this form is not secure for PHI. For more information review our Patient Privacy Policy.