Request a Provider Account

Account Information

Account Name*

Complete Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Fax

Pick Up Schedule*

Daily (Mon-Fri)
Specific Days
Will Call

Please state the days

Payer Mix

% Commercial

% Medicare/Medicaid

% Cash

Expected Volume

Estimated Startup Volume

Estimated Monthly Volume

Lab Results/Reports

Web Portal
Fax

Urine Collection Supply

Requisition Forms
Specimen Cups
Hazard Bags

Shipping Supply

FedEx Lab Packs
FedEx Boxes
Shipping Labels

Contacts / Providers

Physicians

Name

Email

Phone

NPI (Required for all Providers)*

Name	Email	Phone	NPI (Required for all Providers)	Actions
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There are no Physicians.

Maximum number of physicians reached.

Office Manager

Name

Email

Phone

NPI (Required for all Providers)

Sales Representative

Name

Patient Medical Necessity

I am ordering laboratory tests that are reasonable and necessary and for my patient. I agree to provide diagnosis codes for each test that are ordered, to confirm medical necessity and allow Newstar Medical Laboratories to bill on my patient's behalf.

Signature*

Name*

Title*

Date*

Account Information

Contacts / Providers

Physicians

Office Manager

Sales Representative

Patient Medical Necessity

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