New Provider Registration Provider Registration Form Practice Name * Phone * Fax * Website Street Address * Address Line 2 City * State * ZIP Code * Officer manager: first name * Office manager: last name * Phone * Email * Physician Information First name Last name Phone Email NPI Number Medicare participation * Physician participatesPhysician opted outPhysician needs opt-out form Check the box to register a second physician. I would like to register another physician. Register a second physician First name Last name Phone NPI Number Email Medicare participation Physician participatesPhysician opted outPhysician needs opt-out form Check the box to register a third physician. I would like to register another physician. Register a third physician Physician: first name Physician: last name Phone Email NPI Number Medicare participation Physician participatesPhysician opted outPhysician needs opt-out form Practice Hours We are open for business during the specified hours. Day of the week Open time Close time On-Demand Pickup I will call as needed to schedule pickups. Scheduled Specimen Pickup Pick up my specimens at the scheduled times on these days of the week. We schedule pickups Monday-Saturday. Day of the week Start time End time Ordering Paper Requisition Forms Electronic Medical Records (EMR) Please select your preferred ordering method(s). Check all that apply. Report Delivery Electronic Medical Records (EMR) Fax Regular Mail Courier Please select your preferred report delivery method(s). Check all that apply. This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. Submit Δ