PGx Tox form - ADV GEN

PHYSICIAN ENROLLMENT FORM:
Please complete the Practice Registration Form with as much information as possible. If you have not already done so please print off the Acknowledgement and Signature Form and have each physician sign and upload it at the bottom of this page.
Supply Orders
Supplies on all new accounts will be shipped out the same day if the order is in before 1:00pm CT via overnight express shipping. If paper requisitions are requested those will be shipped out along with all new account supplies the following business day express overnight in order to allow for time to pre-print paper requisitions. Please NOTE supplies will be shipped to arrive at any time the day after they are shipped between 9:00am and 3:00pm to the practice.
Print the Acknowledgement and Signature Form.
ACCOUNT MANAGER INFORMATION:
Group ID:*
Your Group Name (optional)
Who you work with directly (optional)
Account MGR Name:*
Account MGR Phone:*
Area CodePhone Number
Account MGR e-mail*
Requested Testing:*
Toxicology
PGx*
Tox Monthly Volume*
Carrier*
Allergy*
Blood Wellness*
Hereditary Cancer*
PRACTICE AND PHYSICIAN INFORMATION:
Name of Practice:
Physician Name:*
First NameLast Name
Specialty:
Type of facility?*
Private PracticeRehabilitation CenterNursing HomeHome Health CareHospitalNone of the above
Phone Number*
Area CodePhone Number
FAX
Area CodePhone Number
NPI Lookup
NPI Number:*
Patient Volume:*
Monthly Volume
Are there other physicians in this office you would like to add?*
How Many?*
Please List All Doctors and NPI #:
ex: Dr. John Jackson - NPI: 1234567891
Do you have more than one location?*
Yes, we have additional locationsNo, we just have one location
How many locations?
Practice Address (accuracy is important for shipping supplies)*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Please reply to the confirmation you receive or send an email to admin@mymailpro.com with the details of each location:

Practice Name
Physician(s)
Address
Phone
Fax
Insurance Mix
IMPORTANT NOTICE:
Alliance Healthcare System can only accept specimens from patients who are insured by Cigna or United Health Care.
UHC Est Volume*
CIGNA Est Volume*
OFFICE CONTACT INFORMATION:
Office Manager:*
First NameLast Name
Same Phone As Above?*
YESNO
Office MGR Phone*
Area CodePhone Number
Office Manager E-mail:*
Hours of Operation:*
COLLECTOR INFORMATION (optional):
Name of Specimen Collector:
First NameLast Name
Same Phone as Above?
YesNo, the collector has a different phone number.
Collector E-mail:
Collector Phone Number:
Area CodePhone Number
REPORTING PORTAL INFORMATION (Web - Secure Portal) MUST BE STAFF MEMBER:
Name of Staff Member Receiving Reports:*
First NameLast Name
Same Phone as Above?*
YesNo, reports are handled differently.
Reporting E-mail*
Phone Number for Reporting:*
Area CodePhone Number
Notes:
SHIPPING PICKUP REQUEST DAYS
MondayTuesdayWednesdayThursdayFridayOther
PICKUP TIMES
2:00pm to 3:00pm3:00pm to 4:00pm4:00pm to 5:00pm5:00pm to 6:00pm
Comments about pickups
SUPPLIES
How Many PGx Kits:*
How Many Tox Kits:*
Would you like supplies shipped to the address above?*
Yes, ship supplies to the practice address.No, please ship to a different address.
Shipping Address
Name
Address
CityState
Zip Code
Comments:
Start Date:*
MonthDayYear
Date
UPLOAD Acknowledgement and Signature Form*
UPLOAD Signature Form
Cancelof
Title
Should be Empty:

SUPPLIES