EHR Vendors — Lab and Radiology Connectivity Requests

Please complete the form to request a new provider lab connection for laboratory or radiology centers not currently on the Change Healthcare Clinical Network. This does not include requests for Labcorp, Quest Diagnostics or other existing lab connections, which should go directly to Implementation via ON24/7, Lab Install Request. For a copy of the latest connectivity listing or to request to be added to the monthly email distribution list for lab updates, please contact Clinical Exchange Sales at ClinicianLeads@ChangeHealthcare.com.

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EHR Vendors Information

EHR Vendor Name*

EHR Vendor Primary Contact*

Contact Phone*

EHR Vendor Primary Contact Email*

Lab/Hospital or Radiology Information

Contact information for Lab/Hospital or Radiology Center that physician is requesting to be connected to

Organization Name*

Organization Address*

City*

State*

Zip Code*

LAB/RAD Sales Rep for Physician Office First Name*(Please do not list organization name here, we need a direct contact at the lab)

LAB/RAD Sales Rep for Physician Office Last Name*

LAB/RAD Sales Rep Direct Line*(Please do not list lab's main number here, we need a direct phone number or email of contact person):

LAB/RAD Sales Rep Email*

Organization Alternate Contact Name

Alternate Contact Title

Alternate Contact Email

Contact Information for Physicians Office

Contact information for Physician Office that is requesting connectivity (Vendor's client)

Physician Office Name*

# of Providers Submitting Orders*

Provider Names Submitting Orders*

Office Address*

City*

State*

Zip Code*

Office Primary Contact Name*

Primary Contact Direct Line*

Primary Contact Title*

Primary Contact Email*

Office Alternate Contact Name

Alternate Contact Title

Alternate Contact Direct Line

Alternate Contact Email

Additional Information

Approximate # of Monthly Requisitions Submitted to Above Lab/Hospital/Radiology*

Additional Notes

Datasets Requested (i.e. lab, radiology, etc.)*

May we contact the physician office if we need additional information on this request?