Provider Application - Recovery Delivered

Please complete the following application and one of our Founders will reach out to you to answer any questions you may have.

PLEASE NOTE: We DO NOT cover Medical Malpractice insurance for 1099 employees. We are happy to introduce you to our medical malpractice company for a quote.

Full Name(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Please Upload a Picture of your State ID

Drop files here or

Max. file size: 50 MB.

Which Type of Provider Are You?(Required)

Medical Doctor

Physician Assistant

Nurse Practitioner

Which of the following services would you like to offer?(Required)

Suboxone

Testosterone Replacement

Hormone Replacement

Weight Loss

In Which State Are You Licensed?(Required)

State License Number(Required)

Please Upload a Picture of your Medical License

Drop files here or

Max. file size: 50 MB.

Please Provide a Sunday to Saturday Availability.

EX: Sunday - Off
Monday - 8am-12pm
Tuesday - 12pm-7:00pm

What is Your NPI Number?(Required)

What is Your DEA Number(Required)

What is Your PTAN Number?

What is Your Tax ID Number?

Comments

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