Provider Application | Mims Express Labs

Apply to Partner With Us

Complete the application below. After it is received, you will be directed to schedule a provider consultation. No payment is required.

Fields marked with * are required. A valid professional license may be requested for account review.

Account Information

First Name *

Last Name *

Degree(s) *

Practice Specialty

Office, Practice, or Facility Name *

Phone Number *

Fax Number

Email Address *

NPI Number Enter the 10-digit NPI, if applicable.

PECOS Status *

Preferred Laboratory

Estimated Monthly Draw Volume

Provider License

Upload Professional License Accepted: PDF, JPG, or PNG. Maximum file size: 5 MB. Do not upload patient records or other protected health information.

Practice or Facility Address

Street Address *

Suite or Unit

City *

State *

ZIP Code *

Billing Contact

Name and Title *

Email Address *

Billing Preference *

Service Needs

Tell Us About Your Needs

Agreement

I confirm that the information provided is accurate and I consent to being contacted by Mims Express Labs regarding this application. *

Your application is sent securely to Mims Express Labs for partnership review. No payment will be collected.