Diagnostic Testing Network Registration

THIS FORM MAY ONLY BE SUBMITTED ELECTRONICALLY. DO NOT MAIL.

Required items are indicated by an *.

Registration For
Administrator
Organization

Registration For

* This Registration is for:

Insurance Carrier/Self-Insured Employer
Insurance Group (Defined by the NYS Insurance Dept. and contains two or more insurance companies.)
Third Party Administrator (TPA)

Administrator Information

* First Name:

* Last Name:

* e-mail Address:

* Area Code: Phone Number: ext.

* Address Line1:

Line 2:

* City: State: Zip Code: Country:

Organization Information

* Insurance Group Name:

* Carrier/Self-Insured Employer Name:

* Board Assigned W Number:

* Third Party Administrator Company Name:

* Board assigned T Number:

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Diagnostic Testing Network Registration

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