Account Registration Request


To register your practice as a client with MedArbor, please complete the Account Registration Request Form below and click Send.  Sometimes additional information is required to complete the registration process.  In such cases, a representative of MedArbor will contact you to complete the registration process.

For assistance, please call us at 888.590.0808 or email us at newaccounts@medarbor.com.

Fill out the new account registration form below:

Name of Practice*

Address*

City*

State*

Zip*

Phone*

Fax*

Practice Contact Name*

Practice Contact Email*

Name of Referring Provider(s), Title, NPI#*





Practice Payer Mix Percentage Breakdown*




Commercial Total %:

Aetna %:

BlueCross/BlueShield %:

Humana %:

Cigna %:

United %:

Medicare %:


Straight Medicare %:

Medicare Replacement Plans %:

Medicaid %:


State Medicaid %:

Medicaid MCO Plans %:

Workers Comp %:

Personal Injury/Personal Injury Protection %:

Uninsured (Self Pay) %:


Services Requested*
UTI/STIRPPWoundWomen’s HealthNail FungalGastrointestinalToxicologyBlood & Wellness

Choose a Preferred Delivery Method for Patient Reporting*
FaxPortalEmail

Specimen Pickup Days*
MondayTuesdayWednesdayThursdayFridaySaturday

Choose a Preferred Courier for Pickup*
FedExUPS

Practice Office Hours*


Name of MedArbor Account Representative*

Email of MedArbor Account Representative*