Client Offboarding Initiation

.

Account Number *

Account Name *

Represetative Initiating Offboarding *

When will be the last day client needs Mako services? * +

Is the offboarding being initiated by the client or Mako? *

Client

Mako

What are the reasons for the offboarding? *

What lab will be providing services to the client moving forward? *

LabCorp

Quest

Unknown

Other Other

Is there an EMR integration to off-board? *

Does the account have scheduled MAKO Courier? *

Yes

Is there a PSR to off-board? *

Yes

What is the Name of PSR to off-board? *

Are there outstanding invoices? *

Yes

Are there any IT assets? *

Yes

Type *

Dymo Printer

Desk Printer

Laptop

Are there any large supply items (centrifuge, phlebotomy chair, refrigerator, etc)? *

Yes