Add Practice

Required fields are marked by a *

Welcome! You're at the right place. All we need from you is to complete the application below. Help is around the corner. And most often, free of charge. We look forward to meeting you soon.

Entity/Organization Information

TAX ID *
TAX ID is required
Legal Business Name Associated with this Tax ID *
How many geographic locations (sites) covered by this ID *
How many patients are in your panel  (estimate) *
Practice Type - (Click all that apply) *
Number Support Staff at the Practice
Website

Business Address Associated with This Tax ID#

Address 1 *
Entity Address is required
Address 2
City *
County *
State *
ZIP *
Phone *
Fax

Entity/Organization Primary Contact

First Name
Last Name
Email Address

Practice Information

Practice Name *
Address 1 *
Address 2
City *
County *
State *
ZIP *
Phone *
Fax
Primary Contact First Name *
Primary Contact Last Name *
Primary Contact Email *

Practice Details

How many prescribing providers are in your practice   (If no prescribing providers, leave blank)
What's your specialty?
If other, please specify
Does your practice see Medicare patients? *
Does your practice see Medicaid patients? *
Does your practice see State Employees Health Plan patients? *
Is your practice owned by a hospital or health system? *
If yes, which system

Add a Provider

Prefix
First Name *
Last Name *
Suffix
Degree *
If other, please specify
Specialty *
If other, please specify
NPI *
License Number *
State *
Medical Director
Provider Champion
To add another provider, complete the form, click the submit button, and answer Yes to the resulting question about submitting another provider.

Health Information Technology (HIT)

If you have an EHR, please select name and version