New Client Information for Build

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.

*Indicates required information

    Preferred Start Date*:

    Your Name*:
    Your Role*:
    Your Email*:

    Office Information: Required

    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:

    Which laboratory will you be sending specimens to?
    Spectrum Health Reference Laboratory, Grand Rapids (SHRL)Spectrum Health Big Rapids Laboratory, Big Rapids (SHBR)Spectrum Health Gerber Laboratory, Fremont (SHGM)Spectrum Health Kelsey Laboratory, Lakeview (SHKL)Spectrum Health Ludington Laboratory, Ludington (SHLH)Spectrum Health Pennock Laboratory, Hastings (SHPH)Spectrum Health Reed City Laboratory, Reed City (SHRC)Spectrum Health United Laboratory, Greenville (SHUN)Spectrum Health Zeeland Laboratory, Zeeland (SHZC)Spectrum Health Lakeland Laboratory, St. Joesph (SHLL)I am unsure
    Primary Laboratory Affiliation if multiple chosen above:

    Operations: Calling Critical Lab Values Required

    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
    Our Office Would Like A Spectrum Health Courier to Pick Up Specimens at Our Office*:YesNo

    If your location needs courier services to pick up specimens collected in the office, please fill out all of the following questions. 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.

    Pick up type:
    Routine pick-ups will be automatically scheduled for specific times and days of the week, only STAT pick-ups or any pick-ups after your pick-up time will need to be called. This should be used if you collect multiple specimens a day, most days of the week. On-call will require your staff to call for a courier pick-up when you have a specimen drawn and ready for pick-up.
    RoutineOn Call
    Best Courier Pick Up Times (NOT ACTUAL. We will try to accommodate your needs):

    Hours of Office Operations:
    Unlocked Building Hours:
    What type of specimens will you be collecting in the office?

    Lockbox type needed:
    Floor modelHanging modelNot neededI have a Spectrum Health lockbox on location If you have a Spectrum Health lockbox at your location, where is it?

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

    Operations: Supplies Optional

    For general supplies, please fill out a Laboratory Supply Requisition given to you by your account manager.


    Daily blood collection volume:


    Daily other collection volume:

    The following is to gage interest and may not be available to all locations, your account manager will work with you to find the best option:

    Operations: Information Services Optional

    Check as many as needed, your account manager will investigate and work with you to find the best option that supports your staff and patients.

    I am interested 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 interested 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 (need faxed 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 Optional

    Spectrum Health Laboratory Billing is performed by the Spectrum Health 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 may 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.

    If Client Billing, reason for use (you are not able to upcharge):

    Physician Owned?
    YesNo

    Will this benefit the physician or a family member directly?
    YesNo

    Tax Exempt?
    YesNo

    Billing Address if different from above (include address, suite number, city, state, zip):
    Billing Contact Name:
    Billing Contact Phone:
    Billing Contact Email:
    Receive statement via (only choose one): emailmailBilling Email if checked:

    Contacts Required

    Office Manager
    Office Manager First and Last Name*:
    Office Manager Email*:
    Office Manager Phone Number*:

    Legal
    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

    Physicians or APPs
    Provider First and Last Name*:
    Provider Email*:
    Provider NPI*:
    Is this the provider's primary location: YesNo
    If No, please list provider's primary location:

    Provider First and Last Name:
    Provider Email:
    Provider NPI:
    Is this the provider's primary location: YesNo
    If No, please list provider's primary location:

    Provider First and Last Name:
    Provider Email:
    Provider NPI:
    Is this the provider's primary location: YesNo
    If No, please list provider's primary location:

    Provider First and Last Name:
    Provider Email:
    Provider NPI:
    Is this the provider's primary location: YesNo
    If No, please list provider's primary location:

    Additional Providers and Contacts. Please include full name, email, phone, and role. If this is additional providers, please include Provider NPI and Provider Primary Practice Name.

    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. A client services representative will respond in 3-5 business days.