Become a AYUMETRIX Provider

We appreciate your interest in becoming a AYUMETRIX Provider and look forward to welcoming you in our network. Please complete the form below and we will contact you and guide you step by step on how to get started. All the fields below are required.

LEARN MORE ABOUT GETTING STARTED WITH AYUMETRIX

If you have any questions, please contact us at 800-215-8898 or info@ayumetrix.com

Name *

Professional Title *

Credentials *

National Provider Identifier (NPI) *

Phone *

Your Email *

Practice Information

Contact Name *

Contact Phone *

Practice Name *

Address*

City *

State*

Zip Code *

Country *

Test Kits you are Requesting

Which test kits are you requesting?*

How many test kits are you requesting?*

How would you like to be contacted? *

How did you hear about us?

Receiving Results

To receive results online in PDF format please provide a valid email address. This email address will be used as your username and also to receive notifications when new reports are available. Upon registration, you will receive an email containing a temporary password.

Email *

Billing

Please choose a billing option *

Provider to Pay: AYUMETRIX will bill provider the special discounted price. The provider will collect payment from patient (check your state regulations). You will be billed monthly for the number of tests that have been performed for your clinic. All billing is charged to the credit card stored on file.

Patient to Pay: Patients pay AYUMETRIX directly.

If you choose “Provider to Pay” option, please send the Autocharge Form separately as a physical signature is required. Account setup will be completed and test kits mailed to you when the signed Autocharge form is received.

Address*

City *

State*

Zip Code *

Comments

Signature

By typing my FULL name below, I indicate that all information is correct and I have read and fully understand my responsibilities for the billing option chosen. I agree to be financially responsible for payment of all charges associated with this account and will inform AYUMEYTRIX if any changes are desired. Also, I acknowledge that only licensed healthcare professionals may order testing for others, and it is my responsibility to understand and abide by any local, state or federal laws that regulate ordering laboratory tests for others.

Provider eSignature*

**Privacy Terms**

We welcome you to contact us at 800-215-8898 or by email at info@ayumetrix.com

CONTACT US
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