EMR Interface Request

EMR Vendor Information
Vendor Name:
Software Name:
Community:
Unrecognized . Additional details are required.
Your Vendor Contact:
Contact Phone #:

Interface Type:	Select Vendor and Software...

Additional Accounts
If you need additional accounts interfaced, please enter and verify them below (account addresses available on mouseover, click red x to remove accounts).
Acct: Zip:

IT Contact at Your Office
IT Contact Name:
IT Contact Phone #:	x

Other Details
Approximately how many total requisitions will you refer to Quest per month? Client's New EMV
Is the EMR you are requesting this interface for live? No Yes
On what date do you expect to start using this interface?
Will you be using Care360 to place orders? No Yes
Will you be creating electronic orders with this interface? No Yes
Will you be using Quest Patient Service Centers? No Yes
Provide a brief justification comment below if needed:

Please review your order and use the Prev button to go back and correct any errors. When your order is correct, please click Submit.

Physician
Name:
Specialty:
NPI #:
License #:
Account Number:

Client's Contact Information
Contact Role:
Contact Name:
Email Address:
Best Phone #:
Best Time to Call:

Office IT Contact
IT Contact Name:
IT Contact Phone #:

Other Details
Est. Monthly Referrals: Client's New EMV
Requested Go-live Date:

Practice
Name:
Street Address:
City, State, Zip:	,
Practice Email Address:

EMR Vendor Information
Vendor Name:
Software Name:
Community:
Interface Type:
Your Vendor Contact:
Contact Phone #:

Additional Accounts
No additional accounts specified.

Justification Comment
Comments here.

When would you expect to begin using the requested interface?
Do these Secondary adds need to be tested before go-live? No Yes
(Please note that if testing is requested the timeline of the implementations will be extended and may not meet the requested Go Live date) .

Project Notes


Additional Accounts
If you need additional accounts interfaced, please enter and verify them below (account addresses available on mouseover, click red x to remove accounts).
Acct: Zip:

Please review your order and use the Prev button to go back and correct any errors. When your order is correct, please click Submit.

Employee
Account Number:

Client's Contact Information
Contact Role:
Contact Name:
Email Address:
Best Phone #:
Best Time to Call:

Office IT Contact
IT Contact Name:
IT Contact Phone #:

Other Details
Requested Go-live Date:

Practice
Name:
Street Address:
City, State, Zip:	,
Practice Email Address:

EMR Vendor Information
Vendor Name:
Software Name:
Community:
Interface Type:

Additional Accounts
No additional accounts specified.

Justification Comment
Comments here.