New Provider Registration Form

Please complete the registration form. Incomplete or inaccurate information may delay processing.

You can access the Provider Support portal through our MorningStar Lab website: https://mslinc.com/

Facility or Clinic Name

Facility or Clinic Address

Ordering Provider Full Name

Ordering Provider Credentials

MD, DO, ND, DC, PA, DPM, NP, FNP or other (specify below)

Provider NPI Number

(10-digit number)

Primary Contact Full Name

Primary Contact Phone Number

Phone

Primary Contact Email Address

Who will be responsible for specimen collection?

In-house staff

Third-party provider

Varies

Do you require us to supply collection kits?

Yes

To request specimen collection kits

Visit URL at: https://app.smartsheet.com/b/form/0118ad73c46b45058a80ce2a7fbee855

Expected sample shipping frequency

Daily

Weekly

On-demand

Expected sample volume (monthly)

Preferred sample shipment days

Our lab is open Monday through Friday.

Important! Schedule your sample shipments between Monday and Thursday. Do not ship on Fridays - to avoid unforeseen delays and the risk of compromising specimen integrity.

Billing Contact Full Name

Billing Address

(Indicate 'same as above' if it is the same as the Facility or Clinic Address)

Billing Phone Number

Phone

Billing Email Address

Billing Payment Method

We accept payment by credit or debit card.

Patient Self Pay

Client Pay - Invoice

Client Pay - cc on file

Insurance

Preferred Method for Test Reports Delivery

Secure Online Portal (Box.com)

LIS Portal (Provider Only) - Complete LIS access request form below

To request LIS portal access

Visit URL at:

https://app.smartsheet.com/b/form/35ed000508a7444e9b680e5c3d4fa6ee

Submitter Full Name

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New Provider Registration Form﻿

New Provider Registration Form