SUCCESS!

Your Request Has Been Submitted.

Your information will be emailed to your Administrator.

ALMOST DONE. Now Complete Step 2 & 3 Below.

Step:2

DOWNLOAD and Fill Out Requisition Form

Requisition Form

Step 3: FAX

FAX Requisition Form, patient insurance information, and insurance card* with patient specimen to: (833) DNA-LAB1 (833-362-5221).

* We accept all insurance and will directly bill patient insurance.

 
xymbio

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

Facility Tax ID/NPI:
Account Type:

Top Three Insurance Payers with Percentage:
PPO:
Medicare:
Other:
 
 
Facility Office Contacts

Administrator
Name:
Email:
Phone:
Fax:

Director of Nursing (DON)
Name:
Email:
Phone:
Fax:

Billing Contact/Back Office
Name:
Email:
Phone:
Fax:

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

Medical Director (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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