Client Intake Form

This form onboards new clients.
MM slash DD slash YYYY
Sales Rep

Account Information

Address
Administrative Contacts (Billing Manager, DON, ADON, Administrator, Office Manager, Medical Director, ..)
Name
Title
Office Phone
Cell Phone
Email
 
Provider Names & Specialties
Name
Title (DO,MD,CRNP, etc.)
PTAN#:
Type I NPI
Specialty
Medical License (State)
email
Phone
 

Service Profile

MM slash DD slash YYYY
Product Lines:
Additional Supplies to be provided by MHS:

Specimen Collection Method

Phlebotomy:
Courier:
STAT:
FEDEX?
Ordering Methodology
Result Delivery
EMR Vendor
Name
EMR Contact Email
EMR Phone
EMR Vendor Acct. #
 
MHS Copia Web Portal Users
Name
Title
Office Phone
Cell Phone
Email
 
Proposed Pricing
Test
Medicare Part A
Client Bill
Patient Bill
 
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