Physician Client Information Form          Fax Form to 678-586-3155

Please provide the following information or you may complete and return the PDF version of this
form. Be sure to include an electronic copy (PDF) of the ordering Health care Practitioner's license
that shows the expiration date or a copy of a voided prescription pad form to ensure the quickest
turnaround time.

General Information
* Indicates Required Information

Practitioner Details
First Name:* ______________________________________  

Last Name:* ______________________________________

Degree(s): _______________________________________

NPI Number, Individual Type 1: _______________________

PECOS Status: ____________________________________

Name of Office or Clinic: _____________________________

Phone Number:* ___________________________________

Fax Number: ______________________________________

Email Address: ____________________________________

Office Contact

Name / Title: ______________________________________

Email Address: ____________________________________

Shipping Address: __________________________________
(Kits and results will be sent to this address)

Line 1:* __________________________________________

Line 2: ___________________________________________

City: _____________________________________________

State/Province: _____________________________________

Postal/Zip Code: ____________________________________

Country:* __________________________________________

Billing Address
Please provide a billing address if it is different from your shipping address.

Line 1: ____________________________________________

Line 2: ____________________________________________

City: ______________________________________________

State/Province: ______________________________________

Postal/Zip Code: _____________________________________

Country: ____________________________________________                       


Online Account (myELN)

We recommend that you make your myELN password non-trivial, memorable, and distinct from any
other that you use online. Passwords must be at least eight characters long, and may contain any
combination of upper and lower case letters, numbers, spaces and/or punctuation. Remember that
you are responsible for the security of your myELN access credentials.

Password: __________________________________________

Confirm password: ____________________________________

Miscellaneous

How did you learn about E-Laboratory Network?* ____________________________

Billing Method Preferences

Allow the following billing methods:
[  ]         Client/Doctor
[  ]         Patient Prepay
[  ]         Insurance
[  ]         Medicare (valid NPI and PECOS enrollment required)

Prompt Pay Agreement

E-Laboratory, Inc will extend the Prompt Payment Fee (Prepay) for services scheduled to the billing
account specified above, provided they meet the following conditions:

Balance in full must be received by the laboratory within 30 days of the statement date.

Please select one of the following options:
[  ]         Remit check within 30 days of the statement date
[  ]         Include payment with the kit when it is sent to the lab for services
[  ]         Authorize the lab to withdrawal funds electronically from your checking or savings bank         
account (If this option is selected, we will fax you additional documentation to complete and return to
us)

[  ]        Provide a credit card with authorization to utilize as an "on-file credit" arrangement

Card Type: ____________________________________________

Credit Card #: __________________________________________

Exp Date:  ______ / ______ / ______

Card Holder Name: ______________________________________