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Interpace Physician Portal

Account Change Request

Please complete the form below to request changes to an existing Interpace Physician Portal account.

If you are looking to register a new account, please use the registration form.

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Changes Requested by:

First Name

Last Name

Email Address

Phone Number

Title / Position

Account Type

Institution Access Physician Access

Division

ENDO (ThyGeNEXT® and ThyraMIR®v2) GI (PancraGEN®, PanDNA®, Fluid Chemistry) Both ENDO and GI

Institution Information (Current Account)

Physician Information (Current Account)

Please specify this information as it is currently in the portal so we may identify your account.

Institution Name

Name of Location/Institution

Physician's First Name

Physician's Last Name

NPI# of Primary Physician

NPI# of Institution (if available)

Street Address (Portal access is granted based on address. Please enter the address found on your current custom requisition.)

City

State

ZIP

Authorizer (Current Account)

Director

Laboratory Director Medical Director

First Name

Last Name

NPI# (if available)

Email

Phone

Account Changes

Select the changes that you are requesting

Update Primary Contact Update Physician and Practice or Institution Information Update Additional Locations (for Physician Accounts) Update Authorizer (for Institution accounts) Update Delegates Disable entire account

Please complete the following fields with the updated information.

Disable Account

Please provide a brief reason for this request

Institution Information (New Information)

Physician Information (New Information)

Institution Name

Name of Location / Institution

Physician's First Name

Physician's Last Name

NPI# of Primary Physician

NPI# of Institution (if available)

Street Address (This new address will replace the address found within your current custom requisition.)

City

State

ZIP

Additional Location #1

Additional Locations

Additional locations can be added only for Physician accounts. To update a location for an Institutional account, please do so within “Update Physician and Practice or Institution Information”.

Action

None Add Location Remove Location

Name of Location / Institution

Street Address

City

State

ZIP

Additional Location #2

Action

None Add Location Remove Location

Name of Location / Institution

Street Address

City

State

ZIP

Primary Contact (New Information)

First Name

Last Name

Email Address

Phone Number

Title / Position

Authorizer (New Information)

Authorizers are needed only for Institutional accounts

Institutional accounts require an authorizing director. Please select below.

Laboratory Director Medical Director

First Name

Last Name

NPI#

Email

Phone Number

Delegate #1

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #2

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #3

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #4

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #5

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #6

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #7

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #8

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #9

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Delegate #10

Should this delegate be added or removed from the account?

Add Remove

First Name

Last Name

Title

NPI#

Email

Finalize Request

Click the "Submit Request" button below to complete the request.

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