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
Provider Questionnaire
Insurance Payment Mix (%)
Testing Requirements & Volume (#)
Provider Account Information
Provider Account / Group Name
Phone
Fax
Email
Primary Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is your shipping address different from your primary address?

YesNo
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EHR
What is the best way to deliver your report?

Portal (via email)FaxBoth
Provider Information
Provider 1 Name

First NameLast Name
Provider 1 Phone
Provider 1 Fax
Provider 1 Email
example@example.com
Provider 1 NPI Number
Who is the point of contact for Provider 1?

ProviderSomeone Else
Provider 1 Point of Contact

First NameLast Name
Provider 1 Point of Contact Phone
Provider 1 Point of Contact Email
Provider 2 Name

First NameLast Name
Provider 2 Phone
Provider 2 Fax
Provider 2 Email
example@example.com
Provider 2 NPI Number
Who is the point of contact for Provider 2?

ProviderSomeone Else
Provider 2 Point of Contact

First NameLast Name
Provider 2 Point of Contact Phone
Provider 2 Point of Contact Email
Provider 3 Name

First NameLast Name
Provider 3 Phone
Provider 3 Fax
Provider 3 Email
example@example.com
Provider 3 NPI Number
Who is the point of contact for Provider 3?

ProviderSomeone Else
Provider 3 Point of Contact

First NameLast Name
Provider 3 Point of Contact Phone
Provider 3 Point of Contact Email
Provider 4 Name

First NameLast Name
Provider 4 Phone
Provider 4 Fax
Provider 4 Email
example@example.com
Provider 4 NPI Number
Who is the point of contact for Provider 4?

ProviderSomeone Else
Provider 4 Point of Contact

First NameLast Name
Provider 4 Point of Contact Phone
Provider 4 Point of Contact Email
Provider 5 Name

First NameLast Name
Provider 5 Phone
Provider 5 Fax
Provider 5 Email
example@example.com
Provider 5 NPI Number
Who is the point of contact for Provider 5?

ProviderSomeone Else
Provider 5 Point of Contact

First NameLast Name
Provider 5 Point of Contact Phone
Provider 5 Point of Contact Email
File Upload

Cancelof
Form Completed By*

First NameLast Name
Should be Empty:

Provider Intake Form

Provider Questionnaire

Provider Account Information

Provider Information