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Register for a Diagnos-Techs™ Provider Account

To request a professional information packet, please fill out and submit the form below. Your information will be forwarded to Diagnos-Techs, Inc.'s Customer Service Department.

All sections marked with an asterisk(*) must be filled in completely for your application to be processed.

Clinic Information

*Clinic/Group:  
*First Name:   *Last Name:  
Title:   Specialty:
License/Cert/NPI:
License Expires:    MM/DD/YYYY

Please Note: A copy of your professional license/certificate must be sent to Diagnos-Techs for verification via fax or email. Please indicate which method of transmittal you will use:      

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

How do you like us to bill you?
(All requisition forms must be marked and signed)
(Payment must be sent with each test)

How do you prefer to receive your patient test results? (Please choose up to 2 options. Also, test results can be viewed/dowloaded by logging into your account on our website)

Practice Information

Practice Type:
Referral How did you hear about Diagnos-Techs?

Directory Information

As an added benefit of having an account with Diagnos-Techs, you are automatically listed on the Provider Directory listing on our website. This listing will be able to be viewed by visitors to the Diagnos-Techs 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: Diagnos-Techs™, Inc. is a Federal and State regulated laboratory. The State of New York has additional licensing requirements¹ that Diagnos-Techs™, 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