Thank You! Your Request Has Been Submitted.

Your information has been entered into our system and will be emailed to your Practice Manager. A copy of your responses can be found below.


You can now order the COVID-19 respiratory panel for your patients.

 
xymbio

New Client: Setup Request
 
Date:
 
 
 
Facility Demographic Information Office Hours
 
Practice Name:
Address:
City:
State:
Zip:

Facility Tax ID/NPI:
Account Type:

Top Three Insurance Payers with Percentage:
PPO:
Medicare:
Other:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:
 
 
Facility Office Contacts

Practice Manager
Name:
Email:
Phone:
Fax:

Billing Contact
Name:
Email:
Phone:
Fax:

Supplies Contact
Name:
Email:
Phone:
Fax:

After Hours Contact
Name:
Email:
Phone:
Fax:
 
 
Physician/Facility Information

Physician (First, Last, Credentials)






Physician NPI





 
 
Reporting Method
Please check all that apply:



 
 
Specimen Retrieval Information

Expected Monthly Volume:
Sample Type:
Requisition Type:
Sample Transportation Method:
Routine:
 
Supply Starter Kit - Send start up supplies to the following address

Name:
Address:
 
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