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!

Referral / Representative Name

Insurance Payment Mix (%)

Testing Requirements & Volume (#)

Provider Account / Group Name*

Is this your first time submitting information for a new account, or are you adding a new provider to an existing group?*

First time – New account setupExisting group – Adding a new provider

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 reports to your providers?

Portal (via email)FaxBoth

When reports are ready for review, who should be notified?

ProviderAssociated contact(s)Both the provider and the associated contact(s)

Please provide the name(s) and email address(es) of the associated contact(s):

Example: Jane Doe – janedoe@clinicname.com, John Smith – johnsmith@clinicname.com

Upload Provider Info (Optional)

If you prefer to submit all provider information as a single file, please upload it here. The file should include: Provider Name, NPI, Phone, Email, Fax, and Associated Contact Name(s) & Email(s).

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

Additional Notes

Form Completed By*

First NameLast Name

Provider Intake Form

Provider Account Information

Provider Information