New Account Form – Boston Heart

Partner with the Boston Heart Team

Complete the form below, and we will contact you when your account has been set up.

Please note: In order to set up a Boston Heart account, you will need to be an authorized ordering provider based on your state guidelines.

Practice Information
Tell us about your practice
Practice Name*
Practice Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Practice Phone*
Practice Fax
Practice Email*
Enter Email Confirm Email
Provider Information
Tell us about up to 3 providers in your practice. More can be added after the account is set up.
First Provider Information
First Provider Name*
First Last Credential
First Provider National Provider Identifier (NPI)*
First Provider Email
Second Provider Information (Optional)
Second Provider Name
First Last Credential
Second Provider National Provider Identifier (NPI)
Second Provider Email
Third Provider Information (Optional)
Third Provider Name
First Last Credential
Third Provider National Provider Identifier (NPI)
Third Provider Email
Healthcare Provider (HCP) Portal Set Up
Please provide information on up to 3 people who will use the Provider Portal. Laboratory reports, Life Plans, and coaching notes are available to you via the portal to ensure that you can stay informed on your patients’ progress. The Practice Admin will have control of the account and will be able to add additional users later.
First Portal User (Practice Admin)
First User Name*
First Last
First User Email*
Enter Email Confirm Email
Second Portal User (Optional)
Second User Name
First Last
Second User Email
Enter Email Confirm Email
Third Portal User (Optional)
Third User Name
First Last
Third User Email
Enter Email Confirm Email
Additional Comments
How did you hear about us?*
Comments
- Yes, i want to receive occasional email updates to the practice email address.
Name
This field is for validation purposes and should be left unchanged.

Customer Care Department

Phone: 877.425.1252
Email: customercare@bostonheartdx.com

Billing Inquiries

Phone: 877.425.1602
Email: billing@bostonheartdx.com

Corporate Headquarters

Boston Heart Diagnostics
200 Crossing Boulevard
Framingham, MA 01702

Partner with the Boston Heart Team

Complete the form below, and we will contact you when your account has been set up.

Practice Information

Provider Information

First Provider Information

Second Provider Information (Optional)

Third Provider Information (Optional)

Healthcare Provider (HCP) Portal Set Up

First Portal User (Practice Admin)

Second Portal User (Optional)

Third Portal User (Optional)

Additional Comments

Customer Care Department

Billing Inquiries

Corporate Headquarters