Provider Registration Form Organization Name*Office Contact* First Last Phone*Fax*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Ordering Providers & AuthorizationProvider Name* First Last NPI #*Provider Name* First Last NPI #*Provider Name* First Last NPI #*Provider Name* First Last NPI #*Provider Name* First Last NPI #*Message*Consent* I hereby authorize Ion Diagnostics and its partners to test, results, and bill all the requisitioned patientsCommentsThis field is for validation purposes and should be left unchanged.
