Carthona Medical Group - Provider Registration

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    Welcome!

    Thank you for choosing Carthona Medical Group to help connect you with a supervising physician. To ensure a smooth and successful collaboration, we kindly ask that you fill out this form with accurate and truthful information. This will allow the MD/DO reviewing your application to make an informed decision regarding supervision.

    Please note that later in the form, we will request the following:

    • Your most up-to-date Resume or CV
    • A Government Issue Photo ID

    Rest assured, this is solely for documentation purposes and will be handled with care and confidentiality as part of our standard protocol.

    *Failure to provide the required information and documents may result in us being unable to process your application.*

     

     

    We look forward to working with you!

  • PROVIDER REGISTRATION FORM

  • Format: (000) 000-0000.
    • ---> Practice Overview & State Requirements 
    • ---> Supervision Details & Meeting Preferences 
    • 8.) What type of supervision do you prefer?*
    • 11.) Do you plan to prescribe controlled substances as part of your practice?*
    • b.) Are you registered with the DEA (Drug Enforcement Administration) for prescribing controlled substances?*
    • d.) Would you like assistance in managing controlled substance prescriptions as part of your collaboration with the supervising physician?*
  • 1.) Do you currently have a Personal Malpractice Insurance Policy?*

  • Important Information Regarding Malpractice Insurance:

    **In order to collaborate with Carthona Medical Group, it is a requirement that you maintain a Personal Malpractice Insurance Policy that includes coverage for supervising physicians. This is essential for the protection of both you and our supervising MDs and DOs. Carthona Medical Group can assist you in obtaining an appropriate policy through our partnered insurance providers.

  • a.) If YES, please provide the following details:

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  • b.) Does your current policy include coverage for supervising physicians?*
  • 2.) If you do not have a Personal Malpractice Insurance Policy, are you willing to obtain a policy that includes coverage for supervising physicians?*
  • Would you like assistance from Carthona Medical Group in finding a malpractice insurance policy that meets these requirements?*

  • Important Note:

    **In order to ensure that both you and your supervising physician are adequately protected, Carthona Medical Group may contact your insurance provider to verify whether supervising physician coverage is included in your policy. We can assist in ensuring that any necessary adjustments are made to your coverage.

  • Do you consent to Carthona Medical Group contacting your insurance provider to confirm coverage on your behalf?*
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  • Target start date of Collaboration/Supervision:*
     - -

  • We want to assure you that all the information you provide in this form will be kept confidential and secure. Your privacy is our priority, and we adhere to the highest standards of data protection.

    Please rest assured that your details are safe with us.

     

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