Register for a DiagnosTechs™ Provider Account



This form is for new account applications only. To update an existing account, please log in to the provider's section of our website here or contact Client Services at 800-878-3787 for further assistance.

All sections marked with an asterisk(*) must be filled in completely for your application to be processed. Note that the Credential "LM" and the Specialty "Midwife" are only available to California and Colorado residents.

Clinic Information

*Clinic/Group:
*First Name: *Last Name:
Credential: Specialty:
*License: NPI:
*License Expires:    MM/DD/YYYY *Licensing Country:
*Application Filled Out By: *Licensing State:

*I certify that it is within my scope of practice to order and interpret laboratory tests according to the regulations set forth by my state for my license.      




Please Note: A copy of your professional license/certificate must be sent to DiagnosTechs for verification via email ([email protected]).


Addresses

*Street Address:
*City/Township: *Country:
Zip Code: State:
*Phone: Fax:
*E-mail:
*Confirm E-mail:
Website:

(Uncheck the box to enter a different address - Please note we cannot ship to PO Boxes)

Preferences

Please Note: All provider billing accounts are required to provide a credit card number.

CC TypeCC Name
CC NumberCC Expiration Date
CC Security Code

*Bill Frequency



*Bill Type
The credit card on file will be charged monthly or per test, as selected above. DiagnosTechs will not bill the patient or accept any payment from the patient directly.
The patient is required to submit payment for all tests submitted prior to results being released. DiagnosTechs will contact the patient directly to resolve any payment issues.

*How do you prefer to receive your patient test results? (Please choose an option. Also, test results can be viewed/downloaded by logging into your account on our website)

Practice Information

Practice Type:
Referral How did you hear about DiagnosTechs?

Directory Information

As an added benefit of having an account with DiagnosTechs, you are automatically listed on the Provider Directory listing on our website. This listing will be able to be viewed by visitors to the DiagnosTechs website who may contact your office directly. If you do not wish to be listed, please indicate your preference by checking the box below.




     


ATTENTION - New York State requirements for sample collection: DiagnosTechs™, Inc. is a Federal and State regulated laboratory. The State of New York has additional licensing requirements¹ that DiagnosTechs™, Inc. has chosen not to pursue. Therefore, we are unable to process samples for New York residents. The test form that comes with the test kit has a section entitled “Important Notice to All Patients”. This section asks if you are a resident of New York and if the sample was collected in New York. If "yes" is the answer to either question, we will be unable to run the test. No restrictions apply on samples collected in any other states.

¹ New York State Public Health Law, Article 5, Title V BS 10 NYCRR SUBPART 58-1