New Client Registration Form - Protocol
ADVERTISEMENT
1
2New Client Registration Form
(General Practice Information)
Practice Name:
Date
Address:
Suite:
City:
State:
Zip:
Phone:
Fax:
E-Mail:
Start Date:
Courier Frequency:
Critical/Panic Contact:
Critical/Panic Phone:
Provider Registration
(If the practice has more the six providers, please use the additional fields on the back.)
Provider Name:
NPI #:
Provider Name:
NPI #:
Provider Name:
NPI #:
Provider Name:
NPI #:
Provider Name:
NPI #:
Provider Name:
NPI #:
Provider Signature Record
(This allows Protocol Laboratories to test specimens submitted according to standard laboratory practices
and seek reimbursement from participating insurance organizations)
Provider Signature:
Date:
Provider Signature:
Date:
Provider Signature:
Date:
Provider Signature:
Date:
Provider Signature:
Date:
Provider Signature:
Date:
Corporate Office &
Diagnostic Laboratory &
Patient Services Center
Patient Services Center
th
2210 7
Street
8394 Rushing Road East
Mandeville, LA 70471
Denham Springs, LA 70726
P: (985) 951-2400
P: (225) 424-6879
F: (985) 951-2404
F: (225) 424-6865
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business