Any practice with up to 4 practice locations.
Any practice with over 4 locations.
Fields marked with an * are required fields.
Primary office address is required. You can add up to 3 additional office locations and still be a solo practice.
Option 1: Individual Document Upload
specialty license.pdf Remove
Option 2: All-in-one Document Upload
Fill out the following information and we will get back to you within 24-48 hours. For immediate assistance call (800) 435-2232 or email email@example.com
If you would prefer to download a copy of the provider application, please feel free to do so. Once you are done filling it out, please email it to firstname.lastname@example.org or fax it to (561) 208-1266