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Accurate Diagnostic Labs - New EMR/Vendor Interface Request

Account Information *
Accurate Labs Sales Rep Filling out Form
Name of Office Staff that put in the Interface Request
Provider Information
Account Address
Type of Interface Requested
Bi-Directional (Orders and Results)
Demographic Interface only
Uni-directional interface built per Management Approval
Does client have custom profiles built that were signed off by the Doctor?
Yes No
Office Contact Information
Office Contact E-mail (if any)
Office Contact Phone Number
Best Day of Week and Time to Call
Office IT Contact Informatin (If Any)
Office IT E-mail Address
Office IT Contact Phone Number
EMR Vendor Information

In order to be able to reach out to EMR Company and avoid any delays, a valid
email address must be provided. Please ensure that all EMR information is obtained.

EMR Vendor
If Other, Please list EMR Vendor Here. (Note that for Practice Fusion interface
requests, the client must put in the request through their Practice Fusion Software.
Practice Fusion is the only EMR that does not require a Jotform)
EMR Vendor Contact Name
EMR Contact E-mail Address
EMR Contact Phone Number
Accurate Diagnostic Labs Sales Representative
Other Details
Hardware Requirements (Check all that apply) Note: Separate request
for hardware must be put in to John Norton
Lab Computer
Label Printer
Installation of EMR on Lab computer
None of the above
The EMR is Already Live
Estimated EMR Go-Live Date (the date the office will begin to use the EMR)
Location and Name for existing Live interface or Additional Accounts
that Should be Linked with Same Interface if any
Please enter additional account number, name and address. If none, write None
Does this second account use the same database?
No (If NO, you must fill out separate interface request form)
Not Applicable
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