Provider InformationRequest Form "*" indicates required fields Step 1 of 2 50% Type of Business* US Practitioner International Practitioner Environmental Provider In an on-going Quality Assurance program at RealTime Laboratories, Inc., and to remain in compliance with HIPAA, College of American Pathology, and CLIA regulations, we are required to maintain a copy of the medical provider’s name, address, phone number, and current license number in the state in which he/she is licensed.Please provide the required information in the attached form and return it within 5 working days. We cannot provide testing services without the completed “RTL Provider Information Request” form, and a copy of the medical provider’s current medical license and NPI #.Name of Provider* Practice Name* Company Name* Title, Degree, or Profession* Practice Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Contact Phone #Contact Email For general correspondanceEmail for Portal For access to patient results through the physician portalFax #NPI #* State License #* License ImageMax. file size: 256 MB.Upload an image or screenshot of your current state licenseHow did you hear about us?*Please SelectReferral from Patient/DoctorIFM – The Institute of Functional MedicineBridgit Danner’s Toxic Mold MasterclassIHS – Integrative Healthcare SymposiumIAQA – Indoor Air Quality AssociationTFIM – The Forum for Integrative MedicineISEAI – International Society for Environmentally Acquired IllnessIPM – Integrative and Personalized MedicineOnline Search/Social MediaILADS – International Lyme & Associated Diseases Society ConferenceAAEM – American Academy of Environmental Medicine ConferenceRealtime's Hosted EventAAMP – Advanced Application Medical PracticesA4M World CongressEHS – Environmental Health SymposiumRealTime Labs/Evexia Educational WebinarOtherOther Are you a MEDICARE provider? Yes No Patient Referral Service* Yes, refer patients to me No, do not refer patients to me RTL receives calls every day from potential patients wanting to speak with a doctor about mold related illnesses. Can we share your practice contact information?Patient receives results through portal?* Yes No Patient will receive an e-mail to access their results the same time the results are uploaded to your portal.Would you like to receive a complimentary starter pack with collection kits?* Yes No Website Pressing Next will take you to an open book quiz that requires an 80% passing rate for you to be listed as one of our recommended Home Remediators. This quiz cannot be saved and completed later so please make sure that you have at least twenty minutes to read the material and take the quiz. The quiz has no time limit. ***Please note that the medical provider’s practice address, listed on the NPI Registry, must match the current practice address we have on file. If the addresses do not match, we are not able to file insurance claims for the provider’s patients. Call 1 -800-465-3203 or visit https://nppes.cms.hhs.gov/NPPES/Welcome.do to make any needed corrections.Physician's Signature "On File" Request FormPhysicians are required to have a signature on file for all providers of RealTime Lab Please keep my signature below, on file at: RealTime Laboratories, Inc. in Carrollton, TX, unless written permission is given to revoke. This signature can be used for attachment to any RTL requisition. I do not authorize this signature to be used for any purpose other than to order a RealTime Laboratories test. Signature* Reset signature Signature locked. Reset to sign again On this date, I provide authorization via the signature above. Environmental Mycotoxin QuizThis quiz is an open book quiz that requires an 80% passing rate for you to be listed as one of our recommended Home Remediators. This quiz cannot be saved and completed later so please make sure that you have at least twenty minutes to read the material and take the quiz. The quiz has no time limit. Test Resources Explanation on the Mycotoxin Panel Wonder Maker’s Mycotoxin White Paper Which mycotoxin is produced by these organisms?Aspergillus flavus, fumigatus, terreus, niger:* Aflatoxins Trichothecenes Ochratoxins Gliotoxins Zearalenone Aspergillus flavus, oryzae, parasiticus, fumigatus:* Aflatoxins Trichothecenes Ochratoxins Gliotoxins Zearalenone Stachybotrys:* Aflatoxins Trichothecenes Ochratoxins Gliotoxins Zearalenone Fusarium:* Aflatoxins Trichothecenes Ochratoxins Gliotoxins Zearalenone Aspergillus niger, ochraceus:* Aflatoxins Trichothecenes Ochratoxins Gliotoxins Zearalenone Which Aflatoxin is the most carcinogenic isomer?* B1 B2 G1 G2 Mycotoxins are formed as part of the growth process of all fungal organisms.* True False Mold colonies accelerate as surfaces get closer to the saturation point.* True False The expansion and contraction of the water supply water supply creates conflict between strains of fungus. Decreasing amounts of water supply can spur the mold colony into releasing as many spores as possible as a survival technique, accelerating a process known as:* Dispersion Acceleration Sporulation A person can look at mold and determine that it makes mycotoxins.* True False The EPA (Chapter 1, Mold Course) tells that there are many mycotoxins from common molds identified. How many did they mention?* 55 88 132 More than 200 What is NOT one of the mycotoxin exposure routes?* Inhalation Sexually Transmitted Ingestion Dermal Absorption Please select all that apply: What are symptoms related to mycotoxin exposure?* Headache Sneezing Runny Nose Skin Rash Increased Asthma Attacks Hypersensitivity Pneumonitis Opportunistic Infections Brain Fog Chronic Respiratory Complaints Eye and Skin Irritation Fatigue Dizziness Dry Mouth Hallucinations Numb Fingers and Toes Which test was developed at RealTime Labs to identify the source of mycotoxins in buildings and to correlate the data to occupant health/medical progress?* ERMI HERTSMI-2 EMMA What is the proper way to collect a sample for the EMMA?* ERMI HERTSMI-2 EMMA How many mold types does the Environmental Relative Moldiness Index identify?* 5 10 26 How many mold types does the Health Effects Roster of Types-Specific Formers of Mycotoxins and Inflammagens identify?* 10 5 26 How many mold types does Environmental Mold and Mycotoxin Assessment identify?* 26 10 5 The ERMI tests for mold and mycotoxins.* True False The HERTSMI-2 tests for mold and mycotoxins.* True False The EPA notes that more than what number of mycotoxins have been identified.* 100 200 400 500 What is the life span of mycotoxins if not eliminated by remediation protocol?* 6 months 1 year 2 years Indefinite Aerosolized fungal particles in chamber studies have shown that fungal fragments are released at up to how many times higher than spores?* 312 413 514 The EMMA test will pinpoint the specific origination location of the mycotoxins in the building.* True False What is the best source for dust collection after remediation is complete for a follow up all clear test.* New AC Filter Return Air Grill Dust Dust From Appliance Surface There is an acceptable level of mycotoxins above the level of detection that would not require further investigation for the source of origin.* True False Mycotoxins are light and small enough that they will escape from the origination point to all levels of the structured home, office, or commercial space.* True False A simple urine test by practitioners provides the mycotoxin information to match with the Environmental Mold and Mycotoxin Assessment test.* True False What does EMMA stand for?* Edible Molds Make Aspergillus Every Mother Makes Appletinis Ewan McGregor Married Anakin Environmental Mold and Mycotoxin Assessment
