OnTarget Consulting Services, LLC
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Clinical Laboratory Inquiry
Name of Account
Salesperson / Group #
Start Date
Physician Last Name
Physician First Name
Office Phone Number
Office Fax Number
Physician Personal Email Address
National Provider Identifier #
Office POC Name
Office POC Email Address
1. Automatic pick-up?
Yes
No
2. PIck-up Special Instructions
3. Results Delivery
Automatic Fax
Hard-copy
On-line Access
4. Hours of Operation
5. Select current EMR system:
eClinicalWorks
Allscripts
Epic Systems
Practice Fusion
NextGen Healthcare
McKesson Provider Technologies
General Electric Healthcare IT
AmazingCharts.com
Cerner
6. How many physicians/practitioners are affiliated with this practice?
OB/GYN - 2 or more
Family Practice - 2 or more
Endocrinologist - 2 or more
Cardiologist - 3 or more
Internist - 3 or more
Rheumstologist - 3 or more
Pain Management Specialist - 1 or more
10+
7. What is your current blood work test menu?
Blood cell counts - Current
Blood cell counts - Future
Cholesterol levels - Current
Cholesterol levels - Future
HIV-related tests - Current
HIV-related tests - Future
Pregnancy - Current
Pregnancy - Future
Substance abuse - Current
Substance abuse - Future
Urinalysis - Current
Urinalysis - Future
Endocrinology - Current
Endocrinology - Future
Genetics - Current
Genetics - Future
Immunology - Current
Immunology - Future
Microbiology - Current
Microbiology - Future
Molecular Diagnostics - Current
Molecular Diagnostics - Future
Oncology - Current
Oncology - Future
Serology - Current
Serology - Future
Toxicology - Current
Toxicology - Future
8. Drug Screen Test Menu
Amphetamines
Barbiturates
Benzodiazepines
Buprenorphine
Cocaine
Ecstasy
Alcohol
Marijuana
Methamphetamine
Opiates
Oxycodone
Phencyclidine
Propoxyphene
Tricyclic Antidepressants
6-Acetylmorphine
Carisoprodol (SOMA)
Fentanyl
Meperidine
Methadone
Thamadol
Creatine
Specific Gravity
pH
9. What is your approximate test volume on a monthly basis?
500 - 1,000
1,001 - 10,000
10,001 or more
10. Who do you use as your Reference Laboratory today or what entity do you intend to use in the future?
Quest Diagnostics
Laboratory Corporation of America
Other
11. Do you need an in-house Phlebotomist?
Yes
No
12. Who is responsible for Phlebotomy? (Lab personnel, Nursing, Medical Assistants, etc).
13. What Healthcare insurance plans do you accept? Check all that apply.
Medicaid
Medicare
HMO
PPO
BlueCross BlueSheild
Humana
United Healthcare
Aetna
Molina Healthcare
Celtic Healthcare
Kaiser Permanente
CIGNA
Assurant Health
14. How many patients in total are seen per day?
10 - 15
16 - 30
31 - 50
51 or more
SPECIAL NOTES:
POL-related Questions Follow:
1. Do you currently have a Physician Office Laboratory (POL) ?
Yes
No
2. If you answered yes to question #1, please list the accreditation agency that you are certified with (COLA, CAP, JACHO, State, etc.).
3. What is your proficiency institution (AAB, API, CAP, AAFP-PT, etc.)?
4. Does this lab serve only your patient group or does it also serve as a Reference Laboratory?
Only My Patients
As a Reference Lab
My Patients and as a Reference Lab
5. What is the highest level of testing performed at your laboratory, or going to be performed?
High Complexity
Moderate/PPM
Waived Testing
6. Do you have any lab personnel and what qualification do they have? (Example: MT, MLT or Technical Lab Assistants, etc.)
7. What instrumentation are you currently using, or going to use?
8. Do you have a Laboratory Information System (LIS)? If yes, what is the LIS you are using?
9. When was your last inspection and what organization conducted it (if any)?
10. Do you currently have a Technical Consultant that monitors your lab (if you have a lab)?
Yes
No
11. When was your last audit (if you have a lab)? Please indicate Month and Year.
12. Who is the Laboratory Director and under what name is (or going to be) the CLIA Certificate/License issued?
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