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PSC Walk-In Account Setup
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Provider Name
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Provider NPI
*
Account Details
Clinic Name:
*
Clinic Address:
*
Clinic City:
*
Clinic State:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Clinic Zip code:
*
Account Contact Information
Primary Contact Name:
*
Primary Contact Email:
*
Clinic Phone Number:
*
Clinic Phone Extension
Clinic Fax Number:
Clinic Billing Contact Name:
Clinic Billing Contact Number:
Billing Contact Phone Extension
Billing Contact Email:
Billing Fax Number:
Preferred Billing Contact Method
Email
Phone
Clinical Contact Information
Please note the appropriate persons to serve as a contact for laboratory staff to relay clinical information, including critical values.
Primary Clinical/Critical Contact Full Name
*
Clinic Contact Phone Number
*
COVID-19 Reporting
Should COVID-19 results be auto-released or first called to a provider?
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Yes, auto-release COVID-19 results.
No, please call all COVID-19 results.