Carthona Medical Group - Provider Registration

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
NAME *

First NameLast NameDegree & Title
Email*
example@example.com
Phone Number*
Address:*
City & State:*
Postal/Zip Code:*
Type of Provider:*
Licensed State/s:*
(List all states where you are licensed to practice.)
DEA Registration (if applicable):
(If you have a DEA registration, please provide the details.)

Please upload your CV (make sure it's up to date).*

(We want to understand your background better to match you with the right physician.)
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Please upload a copy of your government-issued ID.*

(Driver's License, Passport, State ID, or any other valid government-issued identification.)
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Target start date of Collaboration/Supervision:*

MonthDayYear
Date
What is your allocated budget for a collaborating physician?*
Please provide a range, including the minimum and maximum amounts you are willing to allocate. For example, $500 - $700 per month.
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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PROVIDER REGISTRATION FORM