SFRD Diagnostic Laboratory - Partnership & Onboarding Form

Section A: Laboratory Identity & Contact Information

Welcome. The Saba Foundation for Rare Diseases invites you to join our national network as a key diagnostic partner. Your expertise is critical to providing timely and accurate diagnoses for patients on a challenging journey. This form is the first step in building a powerful, technology-driven partnership.

Full Legal Name of Laboratory *

As it appears on your registration documents.

Brand Name (if different)

The name your lab is publicly known by.

Official Website URL

Headquarters Address *

Full registered address of your main facility.

Nodal Officer for SFRD Partnership *

The name of the primary contact person for this partnership.

Nodal Officer's Designation *

Official Contact Email *

A dedicated email for all SFRD communication (e.g., sfrd@yourlab.com).

Official Contact Phone *

A dedicated phone number for the SFRD coordinator.

Section B: Accreditations & Service Portfolio (All fields are mandatory)

This information helps us understand your lab's qualifications and the specific services you offer, ensuring we refer the right patients to you.

Section C: The SFRD Partnership Framework & Workflow

This section outlines the core commitments of our partnership, which is designed to be efficient and impactful for both your lab and our patients.

1. Priority Service Commitment: "We agree to treat all patients referred through the SFRD Network on a priority basis, aiming to reduce turnaround times for sample processing and reporting." * 2. Special Discount Commitment: "We agree to offer a special, preferential discount to all SFRD-referred patients." *

Discount Offered

Please specify the discount (e.g., "30% off our standard rates" or provide a specific price list for key tests).

3. Digital Workflow Integration: "We agree to integrate with the SFRD Network platform. We will assign a coordinator to manage referrals, provide real-time status updates, and securely upload final reports to the platform." *

Section D: Operational & Financial Details (All are mandatory)

This information is necessary to set up your lab on our secure digital platform and enable the payment workflow.

Patient Coordinator Contact *

The person responsible for handling SFRD patient samples and inquiries.

Technical Integration Contact *

The IT person we can contact to set up your lab's role-based access to the SFRD portal.

Bank Account Details *

For receiving payments from patients or co-payments from SFRD.

Agreement to SFRD Co-Pay Model: "We agree to participate in the SFRD co-payment module, where SFRD may pay a portion of the patient's bill directly to the lab for pre-approved, financially needy cases." *

Section E: Consent & Formal Agreement (All are mandatory)

This agreement formalizes our partnership. Please have an authorized representative of your laboratory complete this section.

I confirm that I am an authorized representative of the laboratory named in this form. * I understand that this partnership is voluntary and collaborative. We can choose to end our association at any time by providing 30 days' written notice. * I consent to SFRD securely storing our laboratory's information and listing our lab (Name, Logo, Website, Key Services) in its public directory of trusted diagnostic partners. * Patient Data Confidentiality: We agree to handle all patient data received through the SFRD Network with the strictest confidentiality, in compliance with all national data privacy and medical information regulations. We will not use or share patient data for any purpose other than the requested diagnostic test. * By checking this box, I confirm that all the information provided is accurate to the best of my knowledge and our laboratory agrees to the terms of this partnership. *

Full Name of Authorized Representative *

Designation *

Date

Digital Signature *