CAP Accredited
Legacy Labs
LEGACYLABORATORIES
New Client

New Client Onboarding

Complete this form to begin the onboarding process with Legacy Labs. All fields marked with * are required.

Do Not Submit Patient-Identifying Information (PHI)

This form is for provider and facility information only. Do not include any patient names, dates of birth, medical record numbers, or other protected health information.

Account Information
Facility and location details
Contacts
Primary and escalation contact information

Primary Contact

Critical / Escalation Contact

Business Hours

mondayto
tuesdayto
wednesdayto
thursdayto
fridayto
Shipping & Logistics
Specimen transport and supply needs
Result Delivery & Integrations
How you would like to receive test results
Services
Select the sample types you plan to submit
Providers
Add all ordering providers. Each provider will be sent a signature request after submission.
Provider NameNPICredentialsEmailPhoneSignature StatusActions
No providers added yet. Click "Add Provider" to begin.
Authorization & Acknowledgement
Required acknowledgements and authorizations

Provider Authorization & Acknowledgement

By checking the box below, the authorized representative acknowledges:

  • Responsibility for determining medical necessity for all ordered tests
  • Understanding of applicable payer compliance requirements
  • Commitment to order only tests that are medically necessary
  • Responsibility to maintain supporting documentation for ordered tests
  • Patient consent has been or will be obtained for specimen collection, testing, and release of results to the ordering facility

Electronic Signature Authorization (Optional)

You may authorize Legacy Labs to apply an electronic signature to applicable laboratory documentation for ordered tests.

You may withdraw this consent at any time by providing written notice to Legacy Labs.

Authorized Representative
Final authorization from facility representative

Note: For the public submission form, electronic signatures will be requested via email after submission. Portal users may complete signatures during the wizard process.

Provider-Only Services: Legacy Labs provides laboratory testing services exclusively to licensed healthcare providers and authorized healthcare organizations.

Not Medical Advice: Information provided through this onboarding process and subsequent laboratory services does not constitute medical advice. All clinical decisions remain the responsibility of the ordering healthcare provider.

Emergency Services: If you are experiencing a medical emergency, call 911 or proceed to your nearest emergency room immediately. Laboratory services are not intended for emergency diagnostic purposes.

Data Security: Information submitted through this form is transmitted securely and handled in accordance with applicable privacy regulations. Do not include patient-identifying information in this submission.