BioMed Network Annual Provider Application (Updated June 2022)

BioMed Network Annual Provider Application
Please list your current contact information:
Name of your Organization (clinic/center/practice)*
Name of Lead Practitioner (please include relevant titles/credentials) *
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Organization Description
Organization Email*
example@example.com
Organization Web Address*
Organization Phone Number*

Area CodePhone Number
Organization Fax Number

Area CodePhone Number
Organization Size*
Does your organization accept health insurance?*
Does your organization offer virtual/telehealth services?*
What is/are the discipline(s) that you practice? Select all that apply.

AcupunctureAllopathicAnthroposophicalAyurvedicBiological or BioregulatoryChiropracticCraniosacralDentalEuropean BiologicalFunctionalHolisitcHomeopathicIntegrativeLifestyleMassage/Body WorkNaturopathicOsteopathicPerformance ImprovementPediatricsPrimary CareRegenerativeTraditional Chinese MedicineWomen's HealthOther
Which healthcare disciplines, not listed, are practiced by you or your care providers?
Which of the following consultative and/or therapeutic professionals are employed by your organization? Select all that apply.

AcupuncturistBreathwork TherapistChiropractorCraniosacral TherapistDental HygienistDentistDieticianEstheticianGenetic CounselorHealth CoachLife CoachMassage TherapistMedical Physician (MD, DO)Mental Health CounselorNaturopathic Physician (ND)Nurse Practitioner (APRN)NutritionistOccupational TherapistPeriodontistPersonal TrainerPhysician AssistantPhysical TherapistPsychiatristPsychologistSocial WorkerYoga InstructorOther
Which consultative and/or therapeutic professionals, not listed, are employed by your organization?
Which of the following diagnostic tests does your organization offer on-site?

Bio-Impedance AnalysisConebeam X-RayHeart Rate Variability TestingHormone ProfileLaboratory TestingThermometryThermographyZyto ScanOther
Which diagnostic testing, not listed, is offered by your organization?
Please list additional procedures and/or therapies that your organization offers to clients and/or patients.*
Does your organization specialize in the treatment of certain conditions? If yes, please specify in the space below.*
Please upload a valid diploma or certificate from an accredited college.*

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Please upload a copy of your stated medical license number, if applicable.

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If you do not have a diploma or certificate, please provide a description of the therapy/modality that you or your practice employs.
Have you attended any Biological Medicine lectures, seminars, or participated in trainings, workshops, and/or certificate programs? If yes, please list below.*
Please let us know how you found out about the Biological Medicine Network.
Confirmation*

By checking this box, you are confirming the following: 1) that you, the applicant, has not been the subject of any material allegation or finds of non-compliance or violation of any federal or state regulations relating to the care of service that are subject of the application; 2) that you, the applicant, has not been and is not the subject of any material complaint or past, pending, or threatened litigation relating to the care or services that are the subject of this application.
If the applicant has anything to disclose, please submit an explanation and supporting documentation, either by uploading a document or typing in the area provided below.

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Please enter your explanation here.
Type Name of Applicant (hereby referred to below as "The Applicant")*
I, The Applicant, hereby certify that I have reviewed this application and, to the best if my knowledge, all of the information and materials provided in this application are true and accurate. I agree to promptly notify the Marion Institute, in writing, of any material change to the information provided in this application. I agree that the Marion Institute retains all rights to the Care Provider Locator Tool and all the information provided therein, and in its sole discretion and without prior notice, the Marion Institute may choose to exclude, modify, or delete information provided in the Care Provider Locator Tool.
I, The Applicant, hereby certify that the information provided is truthful and accurate.*

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Type Name Below to Confirm*
Date of signing/submission*

MonthDayYear
Date
Please note: The BioMed Network reserves the right to refuse and/or discontinue a practitioner's listing on its website and referral list. Incusion or exclusion does not constitute endorsement, disapproval or liability on the part of the BioMed Network, the Marion Insitute, Inc. or its governing body. A practitioner being included in the resource database does not guarantee referrals to any clinic.
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