NEW ACCOUNT FORM

New Account Form

Please fill this form to complete the registration process.
Date

Month Day Year
Date
Clinic Profile
Practice Name
Phone
Fax
Address
City
State
Zip
Please ADD Specimen Collector's Name? *

First Name Last Name
What is your Specimen Collector's Phone number? *
What is your specimen collector's Principal Email (Welcome email with further instructions will go to this email address) *
(Lab portal user account will be created for this user to retrieve results online) Please make sure to include a working email.
Physicians and Providers

Any or ALL ordering physicians please include here.
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Name (Last name, First Name)
NPI# / DEA#
Ex. A0039393 / B9483838
Report Delivery Preference

Online Portal AUTO-Fax
Testing & Supplies

PGX COVID-19 Test
Avg Monthly Volume:
Backup Reporting Option:

Email Fax Web portal
Payor Mix % : BCBS vs Medicare:
Pick Up Schedule (If you need a driver in your location, write details below, *

M T W Th F UPS (Preferred) Schedule Driver
Pick up service

UPS (Preferred) Courier (local only) Fedex
Innovative GX Laboratories
5410 Fredericksburg Road, Suite A304 San Antonio TX 78229
Phone: (210) 352-5175

Laboratory Director: Cynthe Sims, PhD, HCLD (ABB) CLIA # 45D2155835
PROVIDER SIGNATURE FORM
I understand that it is my option to select Specific Tests and/or Panels on a Test Requisition Form. Only those tests indicated on the Test Requisition Form will be tested, including reflex testing as documented on the Test Requisition Form. I understand that it is my responsibility to determine the medical necessity of the tests that I have requested for the treatment and/or diagnosis of my patients. Tests that are deemed medically unnecessary may result in a denial of payment and/or penalties.

By signing this document, I acknowledge that I authorize Innovative Genomics and its affiliates to perform testing on my patients from my practice as directed by the individual Test Requisition Forms.

I understand that Innovative Genomics and its affiliates will be billing third parties for the tests I order. In the event that an insurance providers request documentation, I will provide signed written orders from the patient's medical records to the requesting party within 72 hours.
Testing Authorization:
Are you the Physician?

click here if you are filling out this form on behalf of the physician. Please include signed form as an attachment.
Provider’s Signature / Name
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Name

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Who is your Molecular Consultant? - MUST be registered with Innovative GX, before submitting accounts. *
Please make sure you add the person who told you about our lab here.
Please ADD your Molecular Consultant's email - MUST use @Innovativegx.com (E-mail provided during onboarding) *
Please add your FIELD representative email. DO NOT ADD A CLINICS EMAILS HERE ONLY FIELD REPRESENTATIVES
Please include signed form here. ONLY REQUIRED IF SIGNATURE IS NOT CAPTURED WHEN FILLING OUT THE FORM.

Cancel of
Should be Empty:

New Account Form

Clinic Profile

Physicians and Providers

PROVIDER SIGNATURE FORM

Testing Authorization:

Provider’s Signature / Name