SIGNUP MY FACILITY - Hormone Therapy Lab Testing

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Facility Information

Business Name *

The legal entity name of your facility used for tax and license purposes.

Our Office Type

Anti-aging
Cancer Center
Hospice
Emergency
Hospital
Holistic Medicine
Mens Health
MedSpa
OBGYN
Primary GP
Pain Management
Pediatrician
Womens Health
Senior Living

Please click or tap all that apply. A checkbox will appear for your selections. Our lab services can be specifically tailored to your business and patients.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Contact Name *

First

Last

Either yourself or your primary manager for your facility that will have consistent contact from Lions Laboratory.

Email *

Confirm Email

Phone

Date of Birth *

CRITICAL RESULT CONTACT

It is Lions policy to document and notify our facilities of any test results that are resulted within our critical reference ranges.

Contact Name (copy) *

First

Last

Phone

Email *

Billing Information

How Do Your Patients Pay For Labs? *

We do not bill. Our patients primarily use Insurance.
Cash only. We bill patients and you would invoice us.

Patient Insurance Providers (copy)

Allied Pacific
AllCare
Aetna
Anthem Blue Cross
Blue Shield
Blue Shield Trio
Blue Shield 65+
CalOptima
Cigna
Centivo
FairOaks Womens Health
HealthNet
Humana
IEHP
Lakeside
Kaiser
Medicare
Medical
Molina
Optum
Preferred IPA
Regal
Scan
TriCare
United Healthcare

Please mark all that may apply. What Insurance providers do your clients primarily work with? We want to make sure we are in network with your patient bases primary Insurance companies.

Ordering Physicians Only

How many Doctors will be ordering tests at your facility? If you have more than 4 Doctors such as a Hospital, we will send another contact email after signup for additional NPI#’s.

Physician #1 *

First

Last

NPI • 1

Physician #2

First

Last

NPI • 2

Physician #3

First

Last

NPI • 3

Physician #4

First

Last

NPI • 4

Phlebotomist

Does your facility require us to provide a Phlebotomist? *

Yes, we need a Phlebotomist on site for 2 days a week from 9am to 1pm
Yes, My facility is high volume and we need someone here everyday.
No, We draw our own patients blood and do not require

Our drivers will be required to pickup from your lockbox location. Please make sure the Lockbox is visible and our Driver has the key or code to access.

Specimen Pickup Schedule

Average Daily Lab Tests *

What is the average daily total of tests you send out each day? This will help us understand and fulfill the needs of your facility.

Daily Test List

What are the standard most frequent tests that you send out consistently?

Physician Custom Panels

What panels would you like us to create for you? We will add these to your req forms so that you will not have to check each test off individually each time.

Pickup Day(s)

Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Select the days you wish to have specimen pickup. If your clients need daily service, we can arrange daily pickup or multiple pickups to meet your needs.

Pickup Time

Select the time of day for specimen pickup through your staff or after hours. If you do not have a lockbox for samples, one may be provided.

Lock Box

During hours of operation pick up, if so what time?
After hours pick up (Lock box must be visible for the driver to see)

Our drivers will be required to pickup from your lockbox location. Please make sure the Lockbox is visible and our Driver has the key or code to access.

FEDEX OVERNIGHT

Only available for approved locations outside our area

TRAINING FOR PORTAL

If any technical assistance is needed using our portal please email Tony.it@lionslaboratory.com

If you need immediate assistance please contact the main office at (949) 229-0662 option 2.

Trainee Name *

First

Last

Trainee Email *

A username and temporary password will be given to you during your 15-20 minute training session. Lions IT will set up training within the first 48-hours of setting up your account.

Phone *

Training Schedule Request Date & Time *

Date

Time

When would you like our staff to train your staff on how to access, order, review or use the LAB NEXUS portal.

EMR

Aethena
eClinicalWorks
EPIC
Kareo
OTHER

What EMR / EHR software are you currently using?

Additional Notes

Please let us know if there is anything else you require from us, or if there is anything that will help us get to know you better.

Confirmation *

1. I hereby acknowledge that Lions Laboratory will perform laboratory testing for patients from my facilityas indicated on the requisition forms. In addition, Lions Laboratory kindly request 7 days’ notice for thediscontinuation of laboratory services.
2. By signing this form, it is hereby certified that the treating physician shall review the volume,frequency, and duration of testing and order laboratory testing accordingly and in accordance withclinical indication and medical necessity. I understand that it is my responsibility to determine themedical necessity of tests I have requested for the treatment and/or diagnosis of my patients. I agree toprovide diagnosis codes, defined to the highest level of specificity, for each test that I order to confirmmedical necessity and to enable Lions Laboratory to bill on my patient’s behalf.

Authorized Signature Name *

First

Last

Signature *

I hereby acknowledge that Lions Laboratory will perform blood and/or urine testing for patients from my facility as indicated on the requisition forms.

Checkboxes

First Choice
Second Choice
Third Choice