Lab-in-a-Box Account Setup Form

Client Information 

You have requested that your Test Request Forms be printed with the following information:

* denotes mandatory fields

"street address" field is required.
"city" field is required.
"state" field is required.
"zip code" field is required.
"phone" field is required.
"fax where results should be sent" field is required.
"division see supply sheet for divisions" field is required.
"contact person name and title" field is required.
"billing contact person title" field is required.
"physician medical providers name" field is required.
"npi" field is required.
"contact email addresses email addresses are used only for test updates or important notifications" field is required.

Projected Volume

(Please provide what info you have on the following)

Payors

For a list of insurance carriers, click here

"acknowledge that the information provided above is accurate" field is required.
"name agency representative" field is required.