Covid Collection Sites Form

New Collection Sites Form

Please fill this form to complete the registration process.
Client Profile
Date

MonthDayYear
Proposed Start Date

MonthDayYear
This is an ACTIVE/NEW site managed by a collection companyThis is a new site to be managed by Innovative GXOther
Name of Collection Company*
Name of main point of contact*
Main Point of Contact Email*
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who referred you to Innovative GX?*
YesNo
Please email a copy of the coverage to: Compliance@innovativegx.com
Explain*
* Innovative GX will not work with a collection company without proof of liability insurance coverage.
* Every collector needs to have the following completed prior to partnering with Innovative GX
-> Background Check
-> OSHA/HIPAA Training
-> Competency Assessment
COVID PCRRAPID COVID
Collection Site Name *
For IGX sites: Add name of the street and abbreviation of the state. Ex. Innovative Gx Testing Site - Allston St. MA
Site Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Fax
YesNo
Name*
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Contact Email*
example@example.com
(If you are a physician, but you do not have a site manager, please contact us at 1-866-3-DNAPCR ext 2 or at Support@innovativegx.com. We can assign someone for your account.)
If you have a Covid Collector's, please add name below?

Please DO NOT ADD physicians or providers on this field.
Covid Collector's Name

First NameLast Name
WHAT IS YOUR COVID COLLECTOR'S PHONE NUMBER?
PLEASE ADD YOUR COVID COLLECTOR'S EMAIL?
example@example.com
Site Physicians

Any or ALL ordering physicians please include here.
YES, continue below. (Please make sure your Physician sign the form below)NO, I do not have a physician
Name*

Last NameFirst Name
NPI# / DEA#
Ex. A0039393 / B9483838
Name

Last NameFirst Name
NPI# / DEA#
Ex. A0039393 / B9483838
Name

Last NameFirst Name
NPI# / DEA#
Ex. A0039393 / B9483838
ONLINE PORTAL
(LAB PORTAL USER ACCOUNT WILL BE CREATED FOR THIS USER TO RETRIEVE RESULTS ONLINE) PLEASE MAKE SURE TO INCLUDE A WORKING EMAIL. (WELCOME EMAIL WITH FURTHER INSTRUCTIONS WILL GO TO THIS EMAIL ADDRESS)
PLEASE SELECT A USERNAME FOR THE MAIN OFFICE CONTACT OR COLLECTOR? USE FORMAT BELOW*
MUST BE USING FIRST NAME(DOT)LASTNAME: FIRSTNAME.LASTNAME
COVID TESTING & SUPPLIES
AVG Monthly Volume
Initial Shipment will be sent to the client. Average QTY 10-25
Pick Up Options
MTWTHFSatSun

Hours of Operation

Rows	Hours of Operation
M
T
W
TH
F
Sat
Sun

UPS Premier (Preferred)FEDEXSCHEDULE DRIVER (ONLY FOR TEXAS LOCAL ACCOUNTS IN SAN ANTONIO, AUSTIN, HOUSTON)
Local Pick Up Request Form
PROVIDER SIGNATURE FORM

Testing Authorization:
PDF VERSION OF SIGNATURE PAGE. ONLY USE IF YOU ARE NOT WITH THE PHYSICIAN PRESENT
Please upload your signed new account form in here.

ONLY for new account forms with wet physicians signatures.
Cancelof
Site Provider’s Signature / Name
Name

First NameLast Name
Signature

Clear
Name

First NameLast Name
Signature

Clear
YES, please use scheduling tool belowNO, I will contact our SITE MANAGER to schedule our training
IGX CLIENT SERVICES
FOR OFFICE USE ONLY
DO NOT ENTER ANYTHING HERE
EmailDirect MailCustomized Online Advertising
EmailDirect MailCustomized Online Advertising
Should be Empty:

New Collection Sites Form

Client Profile

If you have a Covid Collector's, please add name below?

Site Physicians

COVID TESTING & SUPPLIES

Pick Up Options

PROVIDER SIGNATURE FORM

Site Provider’s Signature / Name