Physician's Enrollment Form- Mako Medical

Physician's Enrollment Form
Clinic/Facility Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Authorization
I acknowledge this form will be used to create my unique login for Apollo Web Portal which will be used to electronically sign patient orders in accordance with CMS requirements. I authorize Mako Medical Laboratories to perform testing on patients from my practice as indicated on individual laboratory service requisition forms and individually signed within Apollo Web Portal.
Physician Name:

First NameLast Name
Provider NPI:
This is always a 10 digit number
Physician's Email:
Mobile Number:
Format: (000) 000-0000.
Signature:
Should be Empty:

Physician's Enrollment Form