Provider Information Request

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 #.

***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.

(A current copy of the State License MUST be included).
Please note, we do NOT distribute your information to any other person or business except for patients, by request.