PracticePlus Enrollment Application

  • Doing Business as Name
  • Legal Entity Name associated with your EIN. Please reference your tax forms if uncertain
  • EIN must be 9 digits / no hyphens please. Please reference tax forms if you are uncertain. NOTE: For practices with multiple locations operating under multiple EIN’s, please submit each via this form separately
  • This is the email that will receive all program communications
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  • Email address of additional practice staff member/person you would like to be included to ensure a quick enrollment
  • Additional Practice Location Address(s)

    Please add the Address, Suite, City, State, Zip for EACH location that shares the same EIN. One primary location will be established per EIN. Points earned from other locations sharing the same EIN will roll up through primary location.
  • NameStreet AddressCityStateZip Code 
  • Wholesale Laboratory Suppliers

  • NameCityStateLab Account # 
    Note: You MUST include the lab name and associated lab account #’s for all participating lab accounts associated with this practice address and any additional practice locations listed. Missing details will result in processing delays
  • W-9 Form Submission

    A W-9 Form signed by the Practice Owner is required as part of the enrollment process. Your enrollment will no be fully processed until we receive your completed W-9 form.
  • Fax Information

    Please fax the completed W-9 form to - 1-866-280-4586
  • Group Affiliation (only one please)