Register Your Practice
We're building a direct pay, no insurance network of high value providers. Please fill out the form below and we'll contact you with more details
Practice Contact
*
First Name
Last Name
Practice Name
*
Best Contact Number
*
E-mail (most of our communication will be via email)
*
example@example.com
Practice Website
https://yourwebsite.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Specialty
*
Please Select
Allergy
Alternative Medicine
Ambulatory Surgery Center (ASC)
Anesthesia/Pain Management
Bariatrics
Behavioral Health
Cardiology
Chiropractor
Dental (includes all sub-specialities)
Dermatology
Endocrinology
ENT
ER/ED (emergency)
Eye (includes all subspecialties)
Genetics
GI (Gastro)
Holistic
Homeopathics
Imaging/Scan Center (radiologist is a separate category below)
Lab Centers
Midwife
Naturopath
Neurology
OB/GYN
Obesity
Oncology
Orthopaedics
Osteopath
Pain Management
Pathology
Physical Therapy
Podiatry
Primary Care
Prosthodontics
Psychiatry
Psychology
Pulmonary
Radiology
Reconstructive Surgery
Rehabilitation
Rheumatology
Sleep
Speech Therapy
Surgery
Urology
Vascular/Vein
Wellness
Wounds
Other (please specify below only if not included)
Specialty (Other)
If not in the dropdown above, please let us know what we're missing
Brief description of your practice
Your interest level in this effort:
I'd like to be part of the group that strategizes on best practice (might involve zoom meetings, phone calls, or other)
I'm ok with responding to email surveys to provide inputs on major direction decisions
I trust the collective and want to be part of the network, but don't want to participate in the planning
I'm not sure, please contact me
Submit Registration
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