New Account Step 1 of 3 – Account Information 33% Account InformationPractice Name PhoneHIPPA Compliant FaxAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Account Type Contact InformationPrimary Contact Name Ordering Physician Name Primary Contact Phone NumberOrdering Physician NPI Account NPI (if applicable) CLIA Number (if applicable) Pecos Yes No Account Startup SurveyTesting Services Requested, Estimated Monthly VolumeToxicologyRPPUTIWoundOTHEROTHEROTHEROTHERWhat is the Carrier Mix?Aetna % BCBC % Cigna % Humana % Medicaid % Medicare % UHC % Client Pay % Self Pay % HMO % Workers Comp % Auto % All Inclusive Contracts % Other Name Other % NOTES By signing below, I certify that the information above is accurate.What is the desired start date? MM slash DD slash YYYY Office Manager Name Office Manager SignatureDate MM slash DD slash YYYY Account Representative Name Account Representative SignatureDate MM slash DD slash YYYY NOTES*Please use one form for each individual location Facility Name Date MM slash DD slash YYYY My signature below serves as verification that the signing provider will ensure that any and all laboratory tests ordered are ordered under my authorization and are medically necessary to ensure patient compliance with the therapy I have prescribed. I am responsible to notify the testing laboratory when I no longer serve as the ordering physician for this account.Provider Signature RecordProvider Name SignaturePecos Enrolled: Yes No NPI Number (required)(Required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Provider Name SignaturePecos Enrolled: Yes No NPI Number (required) NPI Type MD DO PA ARNP Other Note: I understand and hereby acknowledge that I will only order tests that I believe to be medically necessary to ensure patient compliance with the therapy that I have prescribed. The Office of Inspector General (OIG) also takes the position that a provider who orders medically unnecessary tests for which Medicare reimbursement is claimed, may be subject to civil penalties. Facility To Complete(Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email (Select One) Provider Staff Member Name (First & Last): Email CAPTCHA