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Healthcare Provider Application

Apply to become a provider with EpicMD™ in your practice

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Please complete all fields below with information about your practice.
For any questions regarding this form, contact support at: (888) 747-3842.

All information requested is only used by EpicMD™ Medical Advisory Board to qualify applicants for Physician Partnership. Private information or data of any kind is considered personal and will not be shared with any third party.

  • Project Information

    The proposed schedule and your contact from EpicMD™
  • Practice Information

    The demographics of your practice.
  • Please enter a value between 0 and 99.
  • Please enter a value between 0 and 99.
    If so, please provide the following:
  • Please enter a value between 1 and 999999999.
  • Please enter a value between 1 and 999999.
  • Payor Mix

    The mixture of insurance and other payment methods in your practice
  • Please enter a value between 0 and 99.
  • Please enter a value between 0 and 99.
  • Please enter a value between 0 and 99.
  • Please enter a value between 0 and 99.
  • Regulatory Information

    The data needed for due diligence review with EpicMD’s Medical Advisory Committee for eligibility

  • By submitting this form you agree with the EpicMD™ Privacy Policy and Conditions.