New Corewell Health Office

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:

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?
YesNo

Operations: Supplies Optional

For general supplies, please fill out a Laboratory Supply Requisition given to you by your account manager. Items not on the supply list need to be ordered via Workday.

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

Epic Department Name (Example: SHMG IM FM HOLLAND or SHPH IM PEDS SS HAST or SHMG PEDS ORTHO ONC 35):

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"

Contacts Required

Office Manager
Office Manager First and Last Name*:
Office Manager Email*:
Office Manager Phone Number*:
What other Offices do you manage (Office Names)*:

Physicians or APPs
Please make sure you follow the policy and procedures for onboarding CH providers.

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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