Account Setup Form
RESE ARCH. TECHNOLOGY. RESULTS.
www.DiagnosticSolutionsLab.com
cs@DiagnosticSolutionsLab.com
Practice Information: 877.485.5336
ELECTRONIC FORM – PLEASE PRINT IF FILLING OUT MANUALLY! 470.239.5017
EHEALTH SOLUTIONS INC
Company Name: _________________________________________________________________________________________
357 BEAVERVIEW RD
Street Address: __________________________________________________________________________________________
City: ABINGDON VA 24201 USA
_____________________________________State:__________Zip:_________________Ctry:_________________
(276) 821-0373
Phone: _____________________________________________ Fax: _________________________________________________
Primary Contact: BRITNEY BROOKS
__________________________________ 2768210373
Phone:______________________________________________
EHEALTHSOLUTIONSTRUST@GMAIL.COM
Email: ___________________________________________________________________________________________________
Billing Contact: BRITNEY BROOKS
____________________________________ (276) 821-0373
Phone:______________________________________________
EHEALTHSOLUTIONSTRUST@GMAIL.COM
Email: ____________________________________________________________________________________________________
Ordering Clinician(s) Information:
Title/
BRITNEY BROOKS
Name: _____________________________________________ Degree:_______________________
CERTIFIED HEALTH COACH
IMPORTANT
Please attach copy of your
NPI: ________________________________________________ credentials (License/Scope
Title/ of Practice). Diagnostic
Name: _____________________________________________ Degree: _______________________ Solutions is a CLIA regulated
laboratory. Providers must
NPI: ________________________________________________ be licensed or registered in
order to set up an account.
Title/
Name: _____________________________________________ Degree: _______________________ Contact Customer Service
with any questions.
NPI: ________________________________________________
How Did You Learn About Diagnostic Solutions Laboratory?
❏ Conference/Seminar ❏ Colleague ❏ Nutraceutical Company ❏ Patient ❏ Other
Due to state laws physician billing is not available in NY, NJ and RI.
If you would like to set up your account for clinician billing, please include the credit card information below.
Card Type: ❏ Visa ❏ MasterCard ❏ American Express
BRITNEY BROOKS
Name on Card: __________________________________________________________________________________________
4769706066379020 Exp: ___________________
CC# _________________________________ 02/07 609
CR #____________ Zip Code: ___________________
37664
Signature of Card Holder: _______________________________________________________________________________
By signing this authorization, you are authorizing Diagnostic Solutions Laboratory, LLC to charge this card for testing services as they are submitted.
2023-11
