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COVID-19 OVERVIEWNONA SCIENTIFIC
Mike Palmer, [email protected]
Matt Reynolds, Vice [email protected]
Mac McKellar, Director of [email protected]
Nonascientific.com ( 352 ) 260-4700
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NEW ACCOUNT FORM
New Account Form
Date:
Address:
Office Contact:
Collector Name:
Provider Signature:
Provider Signature:
Date:
Date:
Name:
Name:
NPI:
NPI:
City: State:
Office Contact Email:
Collector Phone:
Office Phone:
Collector Email:
Zip: Phone: Fax:
Clinic Specialty:
Send Results: After hours contact for critical results (MD, DO,
NP, PA, RN required):
Clinic/Practice Name: Multi-Office Clinic:
Other:
Account #: Start Date: Sales Rep: Account Manager:
Yes No
ENT
Lab Requisition form: PCR/Serology:
Specimen Swabs: Regular:
Specimen Bags:
Collection Cups/Vacutainer: PCR:
UPS Shipping Supplies:
Needles:
Blood collection supplies:
TOX:
QTY:
QTY:
TOX:
Pernasal:Daily pick-up time:
Call UPS as Needed (Monday-Friday Only)
Monday Tuesday Wednesday Thursday Friday
UPS
Fax
Pediatrician Family Medicine Internal Medicine
Urology Gastro Primary CareGeriatric Medicine
Provider Portal (complete below)
PORTAL STAFF NAME:
1.
2.
PORTAL EMAIL:
1.
2.
Name: Phone:
Hospice Hospital OB/GYN Wound Care Podiatry
ORDERING PROVIDER INFO & ACKNOWLEDGMENT
I acknowledge and agree to conduct my relationship with the
Laboratory in full compliance with all applicable state, local and
Federal laws, including, but not limited to, all healthcare laws
including Federal Social Security Act (including but not limited to
the Medicare and Medicaid Anti-Fraud and Abuse Amendments (42
U.S.C. § 1320a-7a and -7b), the Patient Protection and Affordable
Care Act (Pub. L. No. 111-148, 124 Stat. 119 (2010)), the Federal
Patient Anti-Self Referral Law (42 U.S.C. § 1395nn)) the Health
Insurance Portability and Accountability Act of 1996 42 U.S.C. §§
1320d-1320d- 8 as may be amended and any applicable implementing
regulations thereof and any and all other applicable state statutes
and laws and regulations promulgated thereunder. I understand it is
my sole responsibility to determine and appropriately document
medical necessity for all tests I order for the treatment and/or
diagnosis of my patients. I authorize the Laboratory to perform the
medically necessary testing services I order for my patients as
directed by each individual requisition form I submit. I certify
that (i) I do not have any direct or indirect financial
relationship with any individual or entity whereby I receive any
direct or indirect remuneration, in cash or kind, for the medically
necessary testing services I independently order for my patients,
(ii) I understand that from knowingly causing a false claim to be
submitted may subject me to sanctions or remedies available under
civil, criminal and or administrative law, and (iii) I have
reviewed the Center for Medicare & Medicaid Services’
guidelines and rules related to diagnostic testing services,
including, but not limited to, confirmatory toxicology testing and
baseline testing protocols.
REPORTING
INTERNAL USE ONLY
Checkl ist of i tems left : Shipping Schedule
PRACTICE INFORMATION
FL
8/18/20 Daytona Family Service
123 A1A Ave Daytona 34567 (407) 123-4567 (407) 234-5678
John
Government
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3
NEW ACCOUNT FORM
New Account Form
Date:
Address:
Office Contact:
Collector Name:
Provider Signature:
Provider Signature:
Date:
Date:
Name:
Name:
NPI:
NPI:
City: State:
Office Contact Email:
Collector Phone:
Office Phone:
Collector Email:
Zip: Phone: Fax:
Clinic Specialty:
Send Results: After hours contact for critical results (MD, DO,
NP, PA, RN required):
Clinic/Practice Name: Multi-Office Clinic:
Other:
Account #: Start Date: Sales Rep: Account Manager:
Yes No
ENT
Lab Requisition form: PCR/Serology:
Specimen Swabs: Regular:
Specimen Bags:
Collection Cups/Vacutainer: PCR:
UPS Shipping Supplies:
Needles:
Blood collection supplies:
TOX:
QTY:
QTY:
TOX:
Pernasal:Daily pick-up time:
Call UPS as Needed (Monday-Friday Only)
Monday Tuesday Wednesday Thursday Friday
UPS
Fax
Pediatrician Family Medicine Internal Medicine
Urology Gastro Primary CareGeriatric Medicine
Provider Portal (complete below)
PORTAL STAFF NAME:
1.
2.
PORTAL EMAIL:
1.
2.
Name: Phone:
Hospice Hospital OB/GYN Wound Care Podiatry
ORDERING PROVIDER INFO & ACKNOWLEDGMENT
I acknowledge and agree to conduct my relationship with the
Laboratory in full compliance with all applicable state, local and
Federal laws, including, but not limited to, all healthcare laws
including Federal Social Security Act (including but not limited to
the Medicare and Medicaid Anti-Fraud and Abuse Amendments (42
U.S.C. § 1320a-7a and -7b), the Patient Protection and Affordable
Care Act (Pub. L. No. 111-148, 124 Stat. 119 (2010)), the Federal
Patient Anti-Self Referral Law (42 U.S.C. § 1395nn)) the Health
Insurance Portability and Accountability Act of 1996 42 U.S.C. §§
1320d-1320d- 8 as may be amended and any applicable implementing
regulations thereof and any and all other applicable state statutes
and laws and regulations promulgated thereunder. I understand it is
my sole responsibility to determine and appropriately document
medical necessity for all tests I order for the treatment and/or
diagnosis of my patients. I authorize the Laboratory to perform the
medically necessary testing services I order for my patients as
directed by each individual requisition form I submit. I certify
that (i) I do not have any direct or indirect financial
relationship with any individual or entity whereby I receive any
direct or indirect remuneration, in cash or kind, for the medically
necessary testing services I independently order for my patients,
(ii) I understand that from knowingly causing a false claim to be
submitted may subject me to sanctions or remedies available under
civil, criminal and or administrative law, and (iii) I have
reviewed the Center for Medicare & Medicaid Services’
guidelines and rules related to diagnostic testing services,
including, but not limited to, confirmatory toxicology testing and
baseline testing protocols.
REPORTING
INTERNAL USE ONLY
Checkl ist of i tems left : Shipping Schedule
PRACTICE INFORMATION
FL
8/18/20 Daytona Family Service
123 A1A Ave Daytona 34567 (407) 123-4567 (407) 234-5678
John
Government
FIRST HALF
Date:
8/18/20Clinic/Practice Name:
Daytona Family ServiceMulti-Office Clinic:
Yes No
Address:
123 A1A AveCity:
Daytona
State:
FL
Zip:
34567
Phone:
(407) 123-4567
Fax:
(407) 234-5678
Office Contact:
John
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NEW ACCOUNT FORMSECOND HALF
New Account Form
Date:
Address:
Office Contact:
Collector Name:
Provider Signature:
Provider Signature:
Date:
Date:
Name:
Name:
NPI:
NPI:
City: State:
Office Contact Email:
Collector Phone:
Office Phone:
Collector Email:
Zip: Phone: Fax:
Clinic Specialty:
Send Results: After hours contact for critical results (MD, DO,
NP, PA, RN required):
Clinic/Practice Name: Multi-Office Clinic:
Other:
Account #: Start Date: Sales Rep: Account Manager:
Yes No
ENT
Lab Requisition form: PCR/Serology:
Specimen Swabs: Regular:
Specimen Bags:
Collection Cups/Vacutainer: PCR:
UPS Shipping Supplies:
Needles:
Blood collection supplies:
TOX:
QTY:
QTY:
TOX:
Pernasal:Daily pick-up time:
Call UPS as Needed (Monday-Friday Only)
Monday Tuesday Wednesday Thursday Friday
UPS
Fax
Pediatrician Family Medicine Internal Medicine
Urology Gastro Primary CareGeriatric Medicine
Provider Portal (complete below)
PORTAL STAFF NAME:
1.
2.
PORTAL EMAIL:
1.
2.
Name: Phone:
Hospice Hospital OB/GYN Wound Care Podiatry
ORDERING PROVIDER INFO & ACKNOWLEDGMENT
I acknowledge and agree to conduct my relationship with the
Laboratory in full compliance with all applicable state, local and
Federal laws, including, but not limited to, all healthcare laws
including Federal Social Security Act (including but not limited to
the Medicare and Medicaid Anti-Fraud and Abuse Amendments (42
U.S.C. § 1320a-7a and -7b), the Patient Protection and Affordable
Care Act (Pub. L. No. 111-148, 124 Stat. 119 (2010)), the Federal
Patient Anti-Self Referral Law (42 U.S.C. § 1395nn)) the Health
Insurance Portability and Accountability Act of 1996 42 U.S.C. §§
1320d-1320d- 8 as may be amended and any applicable implementing
regulations thereof and any and all other applicable state statutes
and laws and regulations promulgated thereunder. I understand it is
my sole responsibility to determine and appropriately document
medical necessity for all tests I order for the treatment and/or
diagnosis of my patients. I authorize the Laboratory to perform the
medically necessary testing services I order for my patients as
directed by each individual requisition form I submit. I certify
that (i) I do not have any direct or indirect financial
relationship with any individual or entity whereby I receive any
direct or indirect remuneration, in cash or kind, for the medically
necessary testing services I independently order for my patients,
(ii) I understand that from knowingly causing a false claim to be
submitted may subject me to sanctions or remedies available under
civil, criminal and or administrative law, and (iii) I have
reviewed the Center for Medicare & Medicaid Services’
guidelines and rules related to diagnostic testing services,
including, but not limited to, confirmatory toxicology testing and
baseline testing protocols.
REPORTING
INTERNAL USE ONLY
Checkl ist of i tems left : Shipping Schedule
PRACTICE INFORMATION
FL
8/18/20 Daytona Family Service
123 A1A Ave Daytona 34567 (407) 123-4567 (407) 234-5678
John
Government
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5
FILLING OUT OUR REQ FORM
1
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J o e S m i t h
8:00 1-2-34 SS
08 17 2020M Smith Joe
1-2-343320 SW 33rd Rd.Ocala FL 34474
407-123-4567
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J o e S m i t h
8:00 1-2-34 SS
08 17 2020M Smith Joe
1-2-34
SECTION 1
Section 1
1. Date of Collection
2. Gender
3. Last Name
4. First Name
5. Home Address
6. Telephone Number
7. Date of Birth
Mandatory
1. Check ‘Self Pay’
2. Fill out CDC Required section below.
*Please write legibly
3320 SW 33rd Rd.
Ocala FL 34474
407-123-4567
M Smith Joe
1-2-343320 SW 33rd Rd.
Ocala FL 34474
407-123-4567
08 17 2020
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J o e S m i t h
8:00 1-2-34 SS
08 17 2020M Smith Joe
1-2-34
Section 2
Patient Signature
Section 3
Leave Blank
*Please write legibly
Section 4
Check off applicable diagnosis codes.
SECTION 2 - 4
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J o e S m i t h
8:00 1-2-34 SS
08 17 2020M Smith Joe
1-2-34
Section 5
Check fi rst box - SARS-CoV-2 ( PCR )
*Please write legibly
SECTION 5
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2 1. Make sure specimen tube lid is closed tightly.
2. Legibly fill out the
sticker on the tube
with correct patient
information.
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1. Place filled out specimen
tube into the zip section of
the specimen bag.
2. Place the Req Form with
the appropriate patient
demographics/med list
into the front sleeve of the
specimen bag.
3
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4 1. Fill UPS bag until it is completely full of specimens
(around 8 samples per bag)
before moving to another
bag
2. Close the UPS bag and
place into UPS box which
is provided to protect the
specimens during transit
3. Close the UPS box and
place provided UPS shipping
label onto the box (not the
bag)
ABOUT UPS PICK UP
1. A UPS Placard will be supplied to you by your Nona Scientific
representative.
Place this placard in an easily seen and reachable spot where
your UPS
representative can scan during pickup
2. You will work with your Nona Scientific representative to
come up with ideal
UPS pickup days and times that works for you
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VIEW YOUR REPORTS ONLINECustomized Report
Delivery
- Fax- Online
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VIEW YOUR REPORTS ONLINE
Choose the appropriate program from drop down
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- Read and unread reports
- Easy Search by name
- View reports remotely
VIEW YOUR REPORTS ONLINE
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- View Individual Reports
VIEW YOUR REPORTS ONLINE
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- View Individual Reports
VIEW YOUR REPORTS ONLINE
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FINAL
Patient: SAMPSON, LISA Accession: 9258
Patient #: 2287 Birth: 1/14/1978
Doctor: CUCORANO, IOAN Age: 42 years Collection Date: 6/15/2020
3:00 PM NA
Home Phone: (352)877-8680 Gender: Female Received Date:
6/15/2020 3:21 PM LJ
Test Name Result Units Flag Reference Range/Cutoff
Covid-19 (PCR) Run by LS on 6/16/2020 3:32:44 PM
Covid-19 Not Detected Not Detected
CLIA# 10D2137040Director: Ioan Cucorano, MD, FCAP
Originally Printed On: 6/16/2020 3:57 PM Accession: 9258
Patient: #: 2287
Printed: 6/17/2020 2:48 PM Lab Results for: SAMPSON, LISA
(UTC-05:00) Eastern Time (US & Canada) STAT[S] Corrected [C]
Amended [A] Page: 1/1
EXAMPLEREPORT
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1919
THANK YOUQuestions? Get in Touch+1 407.319.8947
Mike Palmer, CEOmpalmer@nonascientifi c.com
Matt Reynolds, Vice Presidentmreynolds@nonascientifi c.com
Mac McKellar, Director of Salesmmckellar@nonascientifi c.com
O 352.260.4700
F 352.561.2950
info@nonascientifi c.com
3320 SW 33rd Rd. Suite 100
Ocala, FL 34474
