To become a member of our Medical Diagnostic Network, click here to send us an email with the following information or fill out this form and fax it to 1.866.426.8825.

Name of facility/provider

Number of facility/provider locations (please provide the following information for each location)

Address

Phone

Fax

Contact person (Include name and phone #)

Modalities offered

Current PPO participation

Private vendor or part of a larger group

If part of a larger group, what other facilities are there?

Accreditations