Nation Rx Advocates, LLC.

Patient Registration

First Name *

Middle Initial

Last Name *

Password *

Phone

Fax

Is this a smart phone that can receive text?

What is the best time of day to contact you? *

Address *

Address Line 2

City *

State *

Zip *

Time Zone: *

Date Of Birth (mm/dd/yyyy)*

Gender *

Height Ft. *

Height In. *

Weight lbs *

Married

Ethnicity *

Ethnicity Other

Have you done previous genetic testing?

Are you a bone marrow transplant recipient?

Do you have drug allergies?

Policy Holder *

First Name (if not Self) *

Last Name (if not Self) *

Insurance Name *

Insurance Type *

Member ID *

Add Secondary Insurance

Policy Holder

First Name (if not Self)

Last Name (if not Self)

Insurance Name

Insurance Type

Member ID

Patient requests to be assigned to a physician, via telemedicine service, as the primary provider for this test request.

Patient requests to be assigned to a physician, via telemedicine service, if their PCP does not respond to the test request

Patient requests test review by PCP only

Search for Primary Care Physician

Add New Primary Care Physician (PCP)

New Primary Care Physician

PCP First Name *

PCP last Name *

PCP NPI Look Up NPI

PCP Practice Name/Institution

PCP Phone

PCP Fax

PCP Address

PCP City *

PCP State *

PCP Zip

Patient Personal ID Card Front
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Primary Insurance Card Front
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Primary Insurance Card Back
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Secondary Insurance Card Front
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Secondary Insurance Card Back
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Notes