Account Setup

Instructions: Please complete the below form.

Today's Date:*

Services Requested (check all that apply):*

Toxicology
Blood
UTI/STI
COVID
PCR Nail

Diagnostic Service Requested:*

ROM
EMG/NCV
IONM

If transitioning from other services, list which ones:

Account Information

Account Name:*

Main Address:*

Street Address Address Line 2 City State ZIP Code

Phone Number:*

Fax Number:*

If you have additional locations, please list below.

Additional Location Name (If Applicable):

Location Information:

Street Address	Address Line 2	City	State	ZipCode	Phone No.	Fax No.	Email

Additional Location Name (If Applicable):

Location Information:

Street Address	Address Line 2	City	State	ZipCode	Phone No.	Fax No.	Email

Additional Location Name (If Applicable):

Location Information:

Street Address	Address Line 2	City	State	ZipCode	Phone No.	Fax No.	Email

Provider

Specialty:*

Provider Name:*

NPI:*

DEA Reg:*

License No.:*

If you have additional providers, please list below.

Additional Provider(s):

Specialty	Provider Name	NPI

Additional Provider(s):

Specialty	Provider Name	NPI	DEA Reg.	License No.

Clinic Information

Start Date:*

Physician Surgery Day(s):*

Monday
Tuesday
Wednesday
Thursday
Friday

Average number of surgeries performed monthly:*

Ancillary Service Center(s)/Hospital(s) where surgeries are performed:*

Hospital(s) physician has privileges:*

Types of procedures:*

Testing Type (Choose One):*

Traditional (Screening and Confirmation)
Billing Process: The physician’s office does not bill for any testing.
Point of Care (CLIA Waived Cup) or Physician’s Office Lab (Confirmation Only)
Billing Process: Principle HS bills for quantitative (LC/MS/MS) and physician’s office bills for qualitative (screening).

Expected Volume Per Service*

% Payor Mix*

Commercial Insurance	Federal Insurance	Medicaid

Collector Needed:*

Yes
No

Account Contact Information

Main Contact Name:*

First Last

Title:

Main Contact Phone Number:*

Email (Email will receive results portal logins):*

If you have additional contacts, please list below.

Additional Contact(s):

Contact Name	Title	Phone Number	Email

Pickup Service

Pickup Needed:*

Yes
No

Pickup Day(s):

M
T
W
Th
F
Will call when needed. (Please give at least 1 hour notice prior to pickup)

Pickup Time:*

: Hour

Minute

If you have multiple locations with varying pickup days/times, please list below.

Copy location names entered above

Location Name:

Pickup Day(s):

M
T
W
Th
F
Will call when needed. (Please give at least 1 hour notice prior to pickup)

Pickup Time:

: Hour

Minute

Rep Information

Rep Agency:*

Rep Name:*

First Last

Phone Number:*

Email:*

Notes:

Request Supplies

NEW ACCOUNTS AUTOMATICALLY RECEIVE A START-UP SUPPLY KIT.

Additional supplies may be requested online at www.principlehs.com -> Resources -> Request Supplies or by submitting the PHS Supply Request Form directly to supplies@principlehs.com.

Instructions: Please complete the below form.

Account Information

Provider

Clinic Information

Account Contact Information

Pickup Service

Rep Information

Request Supplies

NEW ACCOUNTS AUTOMATICALLY RECEIVE A START-UP SUPPLY KIT.

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