Open a New Account
Date Account Opened:
#		 Month       Day            2014                                                                   # = required field
         
  Must use sliders- No manual entry.
Sender is:
#
Hospital   Coroner-Med.Examiner   Private Practice, MD-DO

Mid-Wife   Individual   Attorney
Address: # 
# 
# 
# 
Contact Info:
#
Primary Contact (person):
 # 
Primary Contact (biss. phone): 10 digits-no spaces
 # 
Primary Contact (cell phone):
 # 
Primary Contact (Fax):
 # 
Primary Contact (pager):
 # 
Primary Contact (email):       valid syntax required
 # 
Emergency Results (person or service):
 # 
Emergency Results (phone - person):  10 dig-0 sp
 # 
Emergency Results (phone - answering serv.):
 # 
Emergency Results (pager):
 #
   Payment
  Options:
  Choose Payment method:
  You must choose at least
  one payment method, and
  a $10.00 transaction
  (creditable to your invoice
  - not refundable) will be
  made to verify the
  payment gateway.
#   Credit Card     Electronic Check   
#   Blanket P.O..  P.O., separate for each specimen.

 Specify later - You may complete this registration and send a specimen immediately, but results will not be released until payment is made. Exceptions are limited to results that if withheld would have an immediate negative impact on a patient.
  Credit Card For a credit card payment you will be directed to credit card payment after you submit this registration.
  Electronic Check

 Routing Number   
Account Number  

Click Here to see a larger image of the sample check
to identify the routing number and account number.
Accounts Payable: For Business Only - Use a p.o. number
Provide contact information to accounts payable. If you have a blanket p.o. number or one use p.o. number now, enter it below:
Blanket p.o.   
One Use p.o.
Accounts Payable (person):
Accounts Payable (phone):
Accounts Payable (Fax):
 # Agreement to pay for services:

I   agree to pay or authorize payment for services performed by Dr. Luquette or his appointees. I realize that Perinatal Pathology Professionals does not bill or accept payment from insurance companies but will provide information to insurance companies at the patient's request or the request of a healthcare provider who sent the specimen, providing the healthcare provider has prior authorization from the patient to communicate with that company (for example: insurance company is listed on the provider's intake records). For efficiency, please list below any insurance company that may be utilized and choose an action for that company.
  No insurance information to record. Do not anticipate sending any.
  No insurance information to record at present, but I do anticipate a need to send in the future.
  Insurance information listed, but no action required at present.
  Insurance information listed, please take the following action:
Contact by: Not Now    phone    fax    email    land mail   
Insur. Co.: 
Address: 
Address: 
Address: 
Address: 
Phone: 
Fax: 
Email: 
Policy No.: 
Policy Holder: 
Covered Party: 
Additional Information: