RELAYHEALTH – RESULTS MANAGER

LABCORP ACTIVATION/UPDATE FORM

Grey areas are for LABCORP USE ONLY
LabCorp Project Number / Date Submitted
LabCorp Project Type / Orders & Results Results Only / Date Activated
Account Status / New Existing / Customer Type / Single Physician Clinic/Multiple Physician
Hospital Other
LCA Sales Rep / Requesting Lab
Phone # / Ext / Production Lab Code
Fax Number / Production Account #’s
Email Address / EDI Transmit Code (RCR)
Lab Contact/EDIS / Orders Routing / zlabbox
Phone # / Ext. / EDI ID (CSID) / Transfer ID
Fax Number / Current EMV
Email Address / Incremental EMV
To be completed by PRACTICE
RelayHealth Patient Communications Capabilities / Bidirectional
(Patient is able to request results & reply to messages) / Unidirectional
(Share results only)
Practice Name / Collection Method / In House COR/PSC LabCorp Phlebotomist
Address / Method Specimens currently submitted / Requisition Script LCM eLabCorp
City /State/Zip / Method Results currently received / Tele-printer FAX LCM eLabCorp
Contact Name/Title / RelayHealth/VAR Rep
(if applicable)
Phone Number / Name
Fax Number / Phone
Email Address / Email
LabCorp Account Number(s) [required for submission]
COMMENTS
Participating PROVIDERS /
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
First Name / Last Name / Suffix / Job Title / Gender / DoB
Medical License / DEA / NPI / Email / Admin Rights-Y/N / Tax Id
Participating STAFF /
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
First Name / Last Name / DoB / Job Title / Email
COMMENTS
.

Form# 1111 7/23/2009 Page 1 of 3