Direct Data Entry for COVID-19 lab results

Organization Information

If you have questions, please email KHIElabs@ky.gov.

Please provide the following details using corporate ownership information. You will have the opportunity, below in the next section, to list the names of each location or site included under this ownership. Please complete just one form per corporate organization.

* Organization Legal Name

Organizationl Name

(If different from above)

* Organization Phone Number

* Address Line 1

Address Line 2

* City

* State

* Zip Code

County

Required for Kentucky Facilities Only

* Will you be reporting the test results of Abbott BinaxNow COVID-19 tests?

Yes

* Do you have an established patient unique identifier system such as a medical record number (MRN)?

Yes

Organization Primary Contact Information

* Full Name

* Phone Number

* Email Address