Provider Service Agreement

1Provider Service Agreement

2Portal Access

Provider Service Agreement*
I accept responsibility for all tests ordered from my office/clinic that are sent to Southwest Regional PCR/MicroGenDX Laboratory. I will still provide a requisition with each sample, which should be deemed as my written request to perform each specified test. I will inform Southwest Regional PCR/MicroGenDX Laboratory, at 1-855-208-0019, if I would like to end this electronic authorization agreement.
By my signature below, I certify the information I provided on and in connection with this form is true and correct to the best of my knowledge. I confirm that I have the authority to submit such an agreement. I also understand that any false statements or deliberate omissions on this form may subject me to legal actions for fraudulent misrepresentation.
- By checking this box, I to agree to the statement above.
Physician Information
Physician First Name*
Physician Last Name*
Practice Name*
NPI Number*
Physical Location
Street Address Address Line 2 City State Zip Code Country
Phone
Fax
Email
Physician Signature*
Date*
MM slash DD slash YYYY

Office/Hospital	Full Address	Phone

Physician Information