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PROVIDER ENROLLMENT FORM
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Provider name
*
Provider Full Address:
*
Provider City/State/Zip:
*
Provider Phone Number:
Provider Fax Number:
After Hours Emergency Phone Number for Critical Results only:
*
Office Hours:
*
Main Contact Name:
*
Main Contact Email Address:
*
Main Contact Phone Number:
Billing Contact:
Billing Address if different than above:
*
Physician Name:
*
NPI Number:
*
How many TOTAL requisitions per month do you estimate to send?
*
Billing Type(s):
Client
Yes
No
Commercial insurance
Yes
No
Medicare
Yes
No
Self pay patient(s)
Yes
No
BCBS of Illinois
Yes
No
Service will be rendered at patient home address?
Yes
No
Service will be rendered at Home health/doctors office?
Yes
No
How do you want to receive your test results?
Fax
Yes
No
Email
Yes
No
Patient Drive Access
Yes
No
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Home
Services
Patient Portal
Health Professional
Insurance Accepted
Order Labs
Provider Enrolment Form
Contact Us
Schedule Appointment
