New Client Account Intake

New Client Account Intake

Standard online intake form based on the extracted fields from IMT_New_Client_Account_Packet.pdf. Preserve field wording as much as practical; all fields are optional unless clearly required.
Company/Account Info
Company Name
Number of Employees
Company Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Company EIN
Company City
Company State
Company ZIP Code
Company Website
Company Phone
Please enter a valid phone number.Format: (000) 000-0000.
Company Fax
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Recipient
Authorized Recipient Name
Authorized Recipient Title
Authorized Recipient Phone
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Recipient Mobile
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Recipient Fax
Please enter a valid phone number.Format: (000) 000-0000.
Reports Secure
Authorized Recipient E-mail
example@example.com
Preferred Method of Reporting
Billing
Billing Address
Billing Attention
Billing City
Billing State
Billing ZIP Code
Billing Phone
Please enter a valid phone number.Format: (000) 000-0000.
Billing Fax
Please enter a valid phone number.Format: (000) 000-0000.
Billing Email
example@example.com
ACH Draft Preference
TPA
Third Party Administrator Name
TPA Address
TPA Attention
TPA City
TPA State
TPA ZIP Code
TPA Phone
Please enter a valid phone number.Format: (000) 000-0000.
TPA Fax
Please enter a valid phone number.Format: (000) 000-0000.
TPA Email
example@example.com
Primary Contact
Last Name
First Name
Middle Initial
Company Name (Contact)
Contact E-mail
example@example.com
Mailing Address
Mailing City
Mailing State
Mailing ZIP Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Payment/Credit Card Authorization
Credit Card Type
Card Number
Expiration Date

MonthDayYear
Date
Security Code
Cardholder Name
Card Billing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Card Billing City, State & ZIP
Cardholder Signature
Cardholder Signature Date

MonthDayYear
Date
Authorization Number (Official Use Only)
Order/Test Request
Employer / Company
Order Date

MonthDayYear
Date
PO #
Donor / Employee
Job Type
ID #
Requested By
Contact #
Please enter a valid phone number.Format: (000) 000-0000.
Test Reasons
Reason for Test

Other
Other Reason for Test (Specify)
Requested Services/Panels
Lab Tests

Other
Audiometry
Vision Testing

Other
Alcohol Testing
Drug Test — Urine (Collection Type)
Drug Test — Urine (Standard Panels)
Urine — Rapid Screen
Hair Drug Test
Oral Fluid Drug Test
Physical Exams

Other
Pulmonary / Fit Test
Mask Type
Special Notes / Instructions
Authorization/Signatures
Authorized Signature
Authorized Signer Title
Authorized Signer Print Name
Authorized Signer Date

MonthDayYear
Date
Should be Empty:

New Client Account Intake

Company/Account Info

Authorized Recipient

Billing

TPA

Primary Contact

Payment/Credit Card Authorization

Order/Test Request

Test Reasons

Requested Services/Panels

Authorization/Signatures