Clinic Account Agreement

Clinic Information

Facility Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Office Phone*

Fax

Office Email*

Company Website URL*

Industry*

How did you hear about us?*

List Sales Representative, Tradeshow or Other Info*

If you selected one of the above from the drop down menu above, list the specific name for the selection

Number of Patients per Day*

Primary Contact Information

This contact will be given full admin access to your portal and will be the primary point of contact for your account. Admin privileges allow this contact to create users and administer privileges within your portal. All communications regarding billing will be sent to this contact.

Primary Contact First Name*

Primary Contact Last Name*

Primary Contact Title*

Primary Contact Cell Phone*

Do you consent to text message communication?*

Yes
No

Primary Contact Email*

Primary Physician Details

Physician First Name*

Physician Last Name*

Physician Title/Credentials*

Physician Cell Phone*

Do you consent to text message communication?*

Yes
No

Physician Email*

NPI # (must have to order with us)*

Additional Ordering Physicians

Add additional clinic physicians. Click the plus sign on the right to add more lines.

First Name	Last Name	Title/Credentials	Email	Cell Phone	NPI # (required)

Special Requests

Projected Specimens

Allergy & Sensitivity

P88 Dietary Antigen Test
P88-DIY Dietary Antigen Test
Precision Airborne Allergy

Medical Wellness

Male Wellness Panel
Female Wellness Panel
Oxidized LDL
Oxidized LDL + Lipids
Advanced Oxidative Stress
Comprehensive Screen

Endocrine

Complete Thyroid Panel
Advanced Adrenal Stress
Male Hormone Profile
Female Hormone Profile

Gastrointestinal

Advanced Intestinal Barrier Assessment
Comprehensive Stool with Parasitology
Helicobacter Pylori Stool Antigen
GI360
G-DAP

Nutrient & Toxic Load

Comprehensive Heavy Metal Urinalysis

Amino Acid

Amino Acid Profile

Billing Preference

Note - The clinic may select multiple payment options or restrict the accounts payable to only one option, however each clinic will be required to keep a credit card on file if Clinician pay is selected. Please select all applicable billing preferences below. If you choose to change the methods of payment in the future, you must submit a Precision Point Diagnostics Revisions & Updates form.

Billing Preferences*

PATIENT PAY - Valid Patient credit card information or a check must be received with the Test Requisition. The patient credit card will be charged immediately upon receipt of the specimen for the lab to process the specimen. If the requisition is missing billing information, we will attempt to collect the information by reaching out to the patient and your clinic for 3 business days. If after 3 business days we cannot acquire the information, the test will be switched to clinician pay and payment will be required from your clinic.
CLINICIAN PAY - A valid Clinic credit card must be on file for all clinics before accepting samples. Any clinics choosing this option will be invoiced & charged immediately for each specimen we receive, unless other arrangements have been agreed upon. If other arrangements are made all invoices are due within 7 days of the invoice date. Any payments received after the 7-day period are considered late.

Other Terms & Conditions

Checks will deposited immediately.
Results are considered released upon upload to the Precision Point Diagnostics Clinician Portal.
Any clinics choosing Clinician Pay option will be invoiced at least twice monthly, unless other arrangements have been agreed upon. All invoices are due within 7 days of the invoice date. Any payments received after the 7-day period are considered late.
Any late payments, returned checks or declined credit cards will incur a 15% or $35 late payment penalty (whichever is greater). Any negotiated discounts may be permanently suspended due to late payment.
Lack of payment in a timely manner will cause a hold to be placed on the account, and new samples will not be queued into production after notification of the "Client Hold" status. In addition, access to the Client Portal will be closed and not reopened until full payment and penalty fees are received.
Failure to pay balances in a timely manner, or failure to honor payment arrangements may result in the account being turned over to collections.
A test requisition, signed by a Provider and patient, and completed accurately is required for samples to be processed. Each Test Requisition represents a legal contract between the Clinician or Clinic. Precision Point Diagnostics, at its sole discretion, will process the Test Requisition as sent until such time as the Clinic updates or amends the Test Requisition.
To make any changes to your account, a Revisions & Updates form must be completed. Note, testing may be delayed if the most up-to-date information is not on file.

ORDERING PROVIDER AGREEMENT by signing the electronic signature for the Clinic Account agreement, I indicate that all information is correct and I agree to be added to the Precision Point newsletter for e-mail updates from the laboratory. Also, I acknowledge that only licensed healthcare professionals may order laboratory testing for others, and it is my responsibility to abide by any local, state or federal laws that regulate ordering tests for others.

PROMPT PAY AGREEMENT By signing the electronic signature for the Clinic Account agreement, I indicate that all information is correct. Also, I understand my specific responsibilities in the payment method chosen. If CLINICIAN PAY is selected above, I agree to be financially responsible for payment of all charges associated with this account.

Email
This field is for validation purposes and should be left unchanged.