877-656-9596

Register As A Provider

If you are not ready to sign up, but would still like more information, contact us.

To sign up for an account, please fill out the provider agreement below. A copy will be emailed to you for your records. For a printable version, please click here.

1 Practice Information



Check this box to opt-in to receive informational and promotional emails from Labrix

2 Primary Practitioner(s)

Please note: Labrix requires that all providers who sign up for a testing account verify that they are allowed to order testing based on the requirements of the state in which they are licensed. Holistic practitioners, nutritionists and health coaches MUST provide the name, designation and license number for a practitioner licensed to order testing. Provide these details in the additional contacts below.
Check this box if this contact will be an ordering provider with an active license. If this box is checked, you must fill out Degree, License Number and provide a scan/photocopy of your license.


Add additional practitioners

3 Office Contact(s)

Type
First Name
Last Name
Suffix
Title
Phone
Email

4 Other Information

Your results will be available online in PDF format. This option requires a valid email address, which will be used as your username as well as receive notifications when new reports are available. Upon registration, you will receive an email containing a temporary password.


5 US & Canada Report Delivery Methods

Email "results ready" notification to:  

6 Prompt Payment Agreement

I wish to participate in the Doctors Data, Inc./Labrix Prompt Payment/Professional Price Discount program. I understand that tests will be charged according to the current Prompt Payment/Professional Price Fee Schedule(s), unless otherwise described below, and I agree to comply with the following:

I understand that if I mark the requisition “Bill Practitioner Account” or select “Always Bill Practitioner Account” option below, charges will be billed to my account, and I agree to pay all outstanding balances in full within 30 days of the invoice date. I understand that all accounts are subject to credit review/approval, that credit limits may be established and that unpaid balances over 30 days old are subject to a monthly service charge of 1.5%.

I understand that patient prepayments on Doctor’s Data tests will be charged according to the DDI Prompt Payment Fee Schedule; and that patient prepayments for Labrix tests will be charged according to the Labrix Collect Fee Schedule.

I understand that the Prompt payment/Professional Price/Labrix Collect fee schedules are not available when “Patient billing or Insurance/Medicare billing” is selected and that these tests will be charged according to the List Price fee schedule.

Practitioners in NY, NJ, and RI may not send payments or have charges billed to their account. In these states, financial transactions by the laboratory may only be made directly with patients.

The undersigned agrees to be responsible for payment for tests billed to his or her professional account and to comply with the terms listed above:

7 Credit Card Authorization


Providing a credit card on file is optional for US accounts and mandatory for all accounts outside the US.

8 Optional Billing Methods Preference