Provider Intake Form

  • Provider Intake Form

  • 2500 E T C Jester Blvd #201, Houston, TX 77008
    T: (713) 485-6965
    F: (832) 218-1090
    E: support@moduslaboratories.com
    CLIA ID: 45D2245388

  • Thank you for taking the time to complete the Provider Intake Form. This form helps us gather the essential information needed to set up your provider(s) in our system and ensure a smooth onboarding experience. Whether you're getting started with us for the first time or adding a new provider to your group, please complete the fields below as thoroughly as possible.

    If you have any questions, feel free to reach out to our team—we’re here to help!

  • Provider Account Information

  • Is this your first time submitting information for a new account, or are you adding a new provider to an existing group?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Is your shipping address different from your primary address?
  • What is the best way to deliver reports to your providers?
  • When reports are ready for review, who should be notified?
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  • Provider Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is the point of contact for Provider 1?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is the point of contact for Provider 2?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is the point of contact for Provider 3?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is the point of contact for Provider 4?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Who is the point of contact for Provider 5?
  • Format: (000) 000-0000.
  • Should be Empty: