Advanced Diagnostic Laboratories

Company Information
Organization Name*
(as shown on invoice)

Address 1*
Address 2
Country
City*
State*
State/Province*
ZIP*
(99999 or 9999-9999)

Company Representative Contact Information
First Name*
Last Name*
Email*
Phone*
Invoice Number(s)
Amount* (9.99)
Payment Type
Billing Information
 Same as Organization Information
First Name*
Last Name*
Business Name
Address 1*
Address 2
Country*
City*
State*
State/Province*
ZIP* (99999 or 9999-9999)
Credit Card Info
Card Type*
Card Number*
CVV2*
Expiration*
Electronic Check
By marking this checkbox, I am authorizing the entered bank account to be charged for the payment amount entered. As payor, I am authorized to conduct transactions from the entered bank account and all information entered is valid. This payment authorization will remain in effect unless I notify its cancellation by sending written notice.
Rounting Number*
Account Number*
Account Type*

Bank Name*
Name on Account*





Refund Policy

Any refund or charge dispute must be requested in writing via email adxlabbilling@njhealth.org or U.S. mail 1400 Jackson St. M011 Denver, CO 80206 within 30 days of the invoice date.

Once samples have been tested and report issued, no refunds will be processed. 
 

Country of Permanent Establishment is the United States of America