Welcome to Synergy Laboratories.

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

Please complete the following account information 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: *

Target Go Live Date: * +

Practice Name: *

Contact Person: *

Phone Number: *

Fax Number: *

Email: *

Street Address: *

Address Line 2:

City: *

State: *

ZIP Code: *

Days of Operation

Lab Services

Lab Services: *

Clinical

Toxicology

Infectious Disease

Pathology

Sample Pickup Days *

Sample Pickup Type *

Lock Box Location *

Sample Pickup Start Date * +

Synergy Account Rep: *

Implementation Manager:

Practice NPI#: *

Are all physicians being submitted registered with PECOS? *

Number of Providers: *

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.

Does your facility engage in Skilled Nursing Facility services? *

New Physician Form

#1 *

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#1 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#2

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#2 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#3

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#3 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#4

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#4 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#5

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#5 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#6

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#6 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#7

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#7 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

#8

	First Name	Last Name	NPI#	Provider Type
Provider Info	First Name	Last Name	NPI#	Provider Type

#8 Provider Numbers

	Medicare#	BCBS#	Medicaid#
Enrollment Info	Medicare#	BCBS#	Medicaid#

Reporting Preferences: *

EHR

iPowerDoc

Fax

EHR

EHR Company Name: *

EHR Account #:

EHR Contact #:

Clinical Critical Results Contact

Critical Contact Name: *

Critical Contact Title: *

Critical Contact Phone #: *

Critical Contact Email: *

Critical After Hours Phone #: *

Billing Information & Contact Details

Billing *

Client Bill

Self Pay

Insurance/Third Party

Billing Contact Name: *

Billing Contact Title: *

Billing Contact Phone #: *

Billing Contact Email: *

Notes

Sure Med Compliance Program

I choose to participate in the SureMed Compliance program.

I hereby acknowledge that Synergy Laboratories will perform the above requested laboratory testing for patients from my practice as assigned and indicated on individual patient Laboratory Requisition Forms, whether in physical copy or digital. I understand it is my responsibility as a physician to assess my 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 my professional judgment to develop individual treatment plans for my patients. I understand it is my 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 my responsibility to properly chart my 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 my responsibility to obtain this documentation from my patients. I will not order tests without first administering the proper risk assessments to justify medical necessity. *

I acknowledge

I understand and agree to the above statement and would like to enter into a partnership with Synergy Laboratories. *

I agree

Name: *

Title: *

Signature: *

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