Provider Registration Page

Ordering and registrations

If you are an existing client, please reach out to us via email. If you are a new client please fill out the new client registration form.

Monday-Friday
8:00AM-9:00PM ET

Tests & supplies:
registrations@cirrusdx.com

Home test kit requests:
homecollection@cirrusdx.com

Training requests:
inservice@cirrusdx.com

Report inquiries:
reports@cirrusdx.com

Billing questions:
billing@cirrusdx.com

Practice name (as it will appear on the report)

Specialty

Address

City

State

Zipcode

Phone

Fax

Estimated sample volume

Method by which reports will be delivered:

Dropbox Fax Email EMR

Include all emails to be added to account

Office contact

Office contact email

Office contact phone

Medicare payor mix

Medicaid payor mix

Commercial payor mix

Practice ordering physican information

Please add name, title, and NPI of additional ordering physicians

Practice Representative Acknowledgement

Each of the parties represents and warrants to the other party in particular with respect to all protected health information (as that term is defined under the standards for Privacy of Individual Identifiable Health Information 94 CFR part 164) as amended from time to time, that it is covered entity (and not a business associate of the other party) under the HIPAA Privacy Regulations and that it shall protect the privacy integrity, security, confidentiality and availability of the protected health information disclosed to, used by, or exchanged by the parties by implementing appropriate privacy and security policies, procedures and practice and physical and technological safeguards and security mechanisms, all as required by, and set forth more specifically in, the HIPAA Privacy Regulation and HIPAA Security regulation as each may be amended from time to time. I hereby acknowledge that Cirrus Dx will perform testing from my practice as directed by my custom profile and by the individual patient Test Requisition Form.

Signature