EMR Vendor Contact Form

Vendor Name

Address

City

State

ZIP/Postal Code

Phone

Website Address

Name of Contact Person

Name of Product:

Are you a VAR? (Value Added Reseller)

If yes, company for which you are a re-seller:

Has your company information recently changed:

If your company name has changed, please provide previous name:

What is your current status with Labcorp:

Please select the type of information you're requesting:

Do you have a customer requesting a Labcorp lab interface?

LabCorp Interface:

Please provide the following customer information. To ensure processing, please complete all fields:

Practice Name

Address

City/Town

State/Province

ZIP/Postal Code

Customer Zip

Customer Phone

Customer Email

Name of practice representative requesting the interface:

Type of interface being requested?

Leave this field blank

Managing Your Health