Provider Service Agreement

 
1Provider Service Agreement
2Portal Access
  • 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.

  • Physician Information

  • MM slash DD slash YYYY
 
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