Welcome to Synergy Laboratories.

We are so happy that you have decided to partner with Synergy Laboratories for these services!

Please complete the information below to assist our IT Team in creating your account.

Dr. Glenn Nelson, Lab Director / CLIA #01D2093765 5570

Rangeline Rd., Mobile, AL 36619

synergytesting.com

(251) 662-9760

Today's Date: *

Practice Name: *

Address: *

Is the physician registered with PECOS? *

According to CMS, providers must be enrolled in PECOS to order laboratory services. Until registered, all orders must be ordered by a PECOS registered provider. Once registered, follow the link below to submit an updated new physician form.

New Physician Form

Provider Last Name: *

Provider First Name: *

NPI: *

Provider Type *

Medicare Provider #:

BCBS Provider #:

Medicaid Provider #:

Acknowledgment *

I understand it is this physician's responsibility to assess their patients' risk factors and order tests based on each specific patient's need(s). I have reviewed the guidelines set forth by state and federal agencies, including but not limited to the Centers for Medicare and Medicaid Services, and agree to utilize the guidelines set forth by these entities along with the physician's professional judgment to develop individual treatment plans for their patients. I understand it is the physician's responsibility to provide Synergy Laboratories with a signed (ink or digital) copy of any Laboratory Requisition Form and authorize Synergy Laboratories to apply this signature to any requisition form transmitted from my office (either physical or digital) in the event that my health care system cannot apply it during transmission. I understand it is the physician's responsibility to properly chart their patients' progress and will provide any applicable information for a patient to Synergy Laboratories upon request if a test has been performed for the requested patient by Synergy Laboratories. I understand that documents that may be requested include but are not limited to: authorization of benefits, consent for treatment, advanced beneficiary notice of noncoverage, and/or progress notes. I acknowledge that it is the physician's responsibility to obtain this documentation from their patients. The physician will not order tests without first administering the proper risk assessments to justify medical necessity. I understand and agree to the above statement and would like to enter into a partnership with Synergy Laboratories.

Name: *

Title: *

Signature: *

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