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I am authorized to sign financial documents for my company.

I am not authorized to sign financial documents for my company.

Complete all required information below, review carefully and hit Finish. PLEASE NOTE: For security purposes, Doctor’s Data does not save your information. If you need to exit the application process before submission, your information will not be saved and you will need to start the application again..

1 Billing Preference

Enable all billing methods and bill as requisition is marked (Default billing method)

Never bill practitioner account; only allow patient prepay, or insurance/Medicare. (Required in NY, NJ, & RI)

Always bill practitioner account; no patient payments, or insurance/Medicare billing. (N/A in NY, NJ, & RI; Required outside USA))

2 Where do you want your bills sent?

Physical Location Courier Address Alternate Address Email Address

3 Credit Card Authorization

Providing a credit card on file is optional for US accounts and mandatory for all accounts outside the US.

I authorize Doctor’s Data, Inc. to charge my outstanding monthly balance to this credit or debit card each month.

Card Type: Visa

MasterCard

American Express

Discover

Name on Card:

Card Number:

Expires:

Cardholder Signature: X

4 Credit Card Billing Address

Name/Attention:

Address 1:

Address 2:

City: Province:

Postal Code: Country:

5 Prompt Payment Agreement

I wish to participate in the Doctors Data, Inc./Labrix Prompt Payment/Professional Price Discount program. I understand that tests will be charged according to the current Prompt Payment/Professional Price Fee Schedule(s), unless otherwise described below, and I agree to comply with the following:

I understand that if I mark the requisition “Bill Practitioner Account” or select “Always Bill Practitioner Account” option below, charges will be billed to my account, and I agree to pay all outstanding balances in full within 30 days of the invoice date. I understand that all accounts are subject to credit review/approval, that credit limits may be established and that unpaid balances over 30 days old are subject to a monthly service charge of 1.5%.

I understand that patient prepayments on Doctor’s Data tests will be charged according to the DDI Prompt Payment Fee Schedule; and that patient prepayments for Labrix tests will be charged according to the Labrix Proffessional Price Fee Schedule.

I understand that the Prompt payment/Professional Price fee schedules are not available when “Patient billing or Insurance/Medicare billing” is selected and that these tests will be charged according to the List Price fee schedule.

The undersigned agrees to be responsible for payment for tests billed to his or her professional account and to comply with the terms listed above:

Name:

Signature: X

Date: