ATC ColorQ Registration
Registration, Change in Frequency, Manual Addition(s) and Deactivation
Authorization of Request
Location Referring Patient to ColorQ
*
Please Select
BAPC
SBAPC
WAPC
EAPC
HFM
CFM
MFM
SBFM
ABPC
COGS
ABFH
EFH
UVMMCCPC
GMIM
TCHC
ATC
HEB
Referring Clinician/Provider
*
First Name
Last Name
Client Authenticity
Client Name
*
First Name
Last Name
Client DOB
*
-
Month
-
Day
Year
Date
Frequency Change/Manual Addition(s)
Is this a request to change ongoing collection frequency and/or manual addition(s)?
Yes (skip down to Frequency of Collections question)
No, I am enrolling a new patient (continue)
Communication Preferences
New patient enrollment
Preferred Method of Notifications (may add more than one)
SMS (add phone number below unless already on file)
Email (add email address below unless already on file)
Dial In (no additional info needed)
Patient Phone Number
Patient Email
example@example.com
Will this be a Tele-Health Collection?
Yes
No
Frequency of Ongoing Collections and/or Manual Addition(s)
Frequency assignment, change in frequency, deactivation, manual addition(s)
Frequency of Collections Request (enrollment, frequency changes, manual request)
*
2-3x/week (Yellow)
2x/week (Maroon)
1-2x/week (Purple)
1x/week (Blue)
2x/month (Green)
1x/month (Magenta)
Every other month (Orange)
4x/year (Teal)
None - Deactivate ColorQ
Every other month (Orange) *odd months
At Appts only (Will not receive ColorQ notifications)
Additional MANUAL Request (add date(s) below)
IOP (Will not receive ColorQ notifications)
For Manual Additions Only:
I want the manual collection request(s)
To be communicated to my patient ASAP, within 24 hours
To be scheduled out (see below)
Both -I want one scheduled for tomorrow and others(s) scheduled out (see below)
Manual Addition Date 1
-
Month
-
Day
Year
Date
Manual Addition Date 2
-
Month
-
Day
Year
Date
Manual Addition Date 3
-
Month
-
Day
Year
Date
Other Information
Other information (Should a collection be observed?):
Remember to Order a Test and SAVE it as a Quick Order in the portal!
Submit
Should be Empty: