Pathology & Clinical Lab Request Intake Form

Pathology & Clinical Lab Request Intake Form

New or Existing Client*

Select

Existing Account Number

Existing Client Request Type*

Select

Contact Name (First, Last)*

Contact Email Address*

Contact Phone Number*

Phone

Facility Phone Number*

Phone

Secure Fax #*

Note: We require a secure fax # for account set-up.

Phone

Laboratory Contact Name (First, Last)*

Note: Lab Contact should be point-of-contact (i.e. Clinical Lab Scientist or Lab Director) most knowledgeable on the types of tests you'd like to send to SHC Reference Laboratory.

Laboratory Contact Email Address*

Laboratory Contact Phone Number*

Phone

How often do you plan to send samples to Stanford Health Care?*

One time only

Multiple

Unsure

Billing Contact*

AP + SP Expected Annual Volume*

Please input the total estimated # of patient pathology specimens.

Note: You must input 0 or Greater.

MP & CP Expected Volume*

Please input the total estimated annual volume.

Note: You must input 0 or Greater.

Use the Test Codes section below to breakdown the estimated volume by Test Code.

Molecular Pathology + Clinical Pathology Test Codes*

Please review our Test Directory HERE to search & provide the SHC Test Codes (see example below).

SHC TEST CODE EXAMPLES:

1. Flow Cytometry: LABPATH24

2. Molecular: LABANTIXA

3. Transfusion: LABTRXNWI

SHC TEST VOLUME BREAKDOWN EXAMPLE:

1. LABPATH24 = 10

2. LABANTIXA = 15

3. LABTRXNWI = 36

Any additional questions or comments? ❔❓

⚠Please, no PHI/HIPAA, no Patient/Personal Information⚠

File Upload 📃⤴

⚠Please, no PHI/HIPAA, no Patient/Personal Information⚠

Please upload your company's documents (i.e. W-9, Registration Forms, etc.)

⚠If you are a single member LLC, or sole proprietorship:

Please do not attach your W-9 here, but email Clinopscontracts@stanfordhealthcare.org

Drag and drop files here or

Send me a copy of my responses

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