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)
				Edit Delete
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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