Client Intake Form This form onboards new clients. Date MM slash DD slash YYYY Sales Rep First Last Account InformationAccount Name:Type II NPI:Parent Company (Contract) Name:Tax ID:Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Locations Multiple Locations? Main Phone:Main Fax:Cell Phone:Website: Account Email: Authorized Signee:Authorized Signee Email: Facility TypeSkilled Nursing FacilityAssisted Living FacilityGroup HomeProvider PracticeHospitalEmployer GroupEmployee/ StaffPersonal CareMemory CareCurrent Census:Current Lab ProviderNumber of Floors/ Units:Insurance Mix:# patients/day:# of beds:Hours of Operation:Insurance Profile:Description or Other Size Indicators:Administrative Contacts (Billing Manager, DON, ADON, Administrator, Office Manager, Medical Director, ..)NameTitleOffice PhoneCell PhoneEmail Add RemoveProvider Names & SpecialtiesNameTitle (DO,MD,CRNP, etc.)PTAN#:Type I NPISpecialtyMedical License (State)emailPhone Add RemoveService ProfileStart Date MM slash DD slash YYYY Product Lines: Clinical Labs Molecular Diagnostics Phlebotomy Courier Select AllAdditional Supplies to be provided by MHS: Centrifuge Refrigerator w/ Freezer Lock Box On Door Lock Box On Ground Other Select AllOther RequestsSpecimen Collection MethodPhlebotomy: Monday Tuesday Wednesday Thursday Friday Select AllCourier: Monday Tuesday Wednesday Thursday Friday Will Call Select AllSTAT: Monday Tuesday Wednesday Thursday Friday Saturday Select AllFEDEX? Yes No Ordering Methodology MHS Web Portal EMR Enterface Result Delivery MHS Web Portal EMR Enterface Via Fax Results Delivery Fax #:EMR VendorNameEMR Contact EmailEMR PhoneEMR Vendor Acct. # Add RemoveMHS Copia Web Portal UsersNameTitleOffice PhoneCell PhoneEmail Add RemoveProposed PricingTestMedicare Part AClient BillPatient Bill Add RemoveAdditional Comments:
