To complete your application, you will need the following information:

1. Profile Information about you as the provider

2. Information about your Medical Health Insurance Plan

3. A copy of your Health Plan Proof of Coverage*

*This documentation should provide details that verify your name as the policy holder, your health care plan name, and the coverage period.

Downloadable form is also available.


If you need additional assistance during the application process, we’re here to help.
Please call (833) 714-6028 or email [email protected].

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