New Client Information for Build

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 Corewell Health Laboratory? If Yes please provide a list of account names and addresses:

Which laboratory will you be sending specimens to?
Corewell Health Reference Laboratory, Grand Rapids (CHRL)Corewell Health Big Rapids Laboratory, Big Rapids (CHBR)Corewell Health Gerber Laboratory, Fremont (CHGM)Corewell Health Kelsey Laboratory, Lakeview (CHKL)Corewell Health Ludington Laboratory, Ludington (CHLH)Corewell Health Pennock Laboratory, Hastings (CHPH)Corewell Health Reed City Laboratory, Reed City (CHRC)Corewell Health United Laboratory, Greenville (CHUN)Corewell Health Zeeland Laboratory, Zeeland (CHZC)Corewell Health Lakeland Laboratory, St. Joseph (CHLL)Only sending to Corewell Health Outpatient Draw SiteI'm unsure/other
Primary Laboratory Affiliation if multiple chosen above:
Do you utilize any other labs for services?*
If yes, what other services are you receiving?
Will Corewell Health Labs be your primary lab?*

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.

I understand that our providers may be contacted afterhours to receive critical lab result information (checkbox must be checked)*
Back Line Office Phone Number:
After Hours Critical Phone Number*:
Critical Phone Instructions*:

Operations: Courier Services
Our Office Would Like A Corewell 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?
BloodBody FluidBone MarrowCSFFNAPapStoolSwabTissueUrine

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

Will you be sending patients to a Corewell Health (Spectrum Health) Draw Site?
Yes

Operations: Supplies Optional

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

Our office will be collecting blood specimens
Daily blood collection volume:

Our office will be collecting other specimens (paps, biopsies, urines or stools)
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:
Our office will need a centrifugeOur office will need a label printerOur office will need phlebotomy trainingOur office will need an embedded phlebotomist

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 Corewell Health's Online Portal (EpicCare Link)I am interested in using Corewell Health's version of Epic as my EMR (Epic Community Connect)I am interested in setting up an interface with my EMR and Corewell 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

Corewell Health Laboratory Billing is performed by the Corewell 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.

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