Lenco Lab

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Diagnostic testing at its best. With commitment.

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Account Setup

Lenco Diagnostic Laboratories, Inc.

Main LabDaq# Today’s Date Effective Date
/

Name & Address

Name:
Name 2:
Street:
City: ST: ZIP:
Phone #: Fax #: Email:
Contact: Ext:

Payors & Pricing

BILL TYPE
* if Client Bill/ANY special prices – must attach Approval Form. After approval, must forward special prices to billing
Ordering Physician:
NPI #:
License #:
** see below to add additional physician information

Logistics

Office Hours: Pick-Up Times:
MONDAY –  – 
TUESDAY –  –  [
WEDNESDAY –  –  Bldg Keys# Office Keys#
THURSDAY –  –  Time stop: Before: After:
FRIDAY –  –  Box Loc.
SATURDAY –  –  Contact Person:
SUNDAY –  –  Nearest Cross Street:
Loc. of office in Bldg:
Where To Deliver: Reports: Supplies:
Location of Spec Pick-up:
After Hours:

Client Supplies

Req’s: .
Quantity Each:
GEN Test Req. Cyto / Tissue
No-Body Req. HIV
Allergy Supply Order Req.
Ob/GYN Other:
Pre-Prints Requested by form: Standard Tests/Profiles ONLY Custom profiles/panels require signed Client request form prior to printing on reqs.
Please forward all Client Supply Requests to the Client Supply Department supplies@lencolab.com
Compliance Statement: In accordance with applicable laws, Lenco Diagnostic Laboratories Inc. may provide only those supplies directly related to collect, preserve and transport specimens in quantities proportionate with the number and type of specimens received. (Supplies are allocated to clients based on average specimens received. The supply system will not allocate supplies based on past specimen volume history for 2 to 3 months until new history at higher specimen volume level is established.)

Additional Payor Information (Group Practice)

Ordering Physician NPI# License#
LencoLink Setup Date welcome letter created: Date given to Rep/Acct:
Main Labdaq # Linked accts:
RESULTs DELIVERY Method(s):
EMR/EHR: Contact: Phone:
Email:

Physician Office Hardware/Services Requested
(hardwired connection only for autoprint)

Signed and dated Lenco Hardware Agreement MUST be attached before any work will be scheduled.
Office IT contact: Phone: Email:
Install Date requested: Time preferred:
(please leave at least 72 hours to schedule, 3 hour window to complete work.)
* Misc. Instructions:

Cytology/Pathology Connectivity Request