OEIS National Registry Participant Sign-Up Form

Please complete one form for each participating physician.


First name as it appears in the NPI system


Last name as it appears in the NPI system




Jr, Sr, III etc


NPI and Tax ID Number should match exactly as those used on Medicare B claims that are submitted at your site. This is critical to ensure CMS accepts the data in this Registry.








Enter the name of the site of your primary lab used to enter Registry data.


If different from Location Name










NPI and Tax ID Number should match exactly as those used on Medicare B claims that are submitted at your site. This is critical to ensure CMS accepts the data in this Registry.






Please enter the work email address to be used for all communication and correspondence regarding this Registry.








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