Before You Begin
STOP: This form is to be completed by authorized personnel only. To avoid delays or incomplete submissions, please ensure you have the following information ready before launching the form.
What You'll Need:
- Billing Information – including billing address, and contact name for those generating Purchase Orders (PO's).
- Written Medical Protocols – if applicable to your request.
- Designated Employer Representative (DER) Contact Email and Phone Number – for form processing and follow-up.
Incomplete forms cannot be processed and may result in service delays. When you have ALL of the required information, click below to proceed.