Provider Enrollment Form

The information you provide will be used to develop the network, coordinate services, generate bios, and develop products. Allevion will use your name, photo, likeness and/or biography related to your role as a healthcare provider in various materials that may be publicly accessible, such as the Surgeo surgery package portal. It will be used to verify your professional history, including with the National Practitioner Data Bank and government licensing agencies.

Please remember to click the SUBMIT button when you are done.

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    Case Volume & Complication Rates

    Allevion may be able to arrange for products that would pay expenses in the event of complications. The data collected in the following three questions will be shared with the underwriter.
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    Here is a sample display of a Surgeo surgery package.

    (not real data)

    One last thing ...

    Please email the following to enrollment@allevion.com 1. CV 2. Photograph We will email you a Docusign populated with the information you provided. Please sign this document as soon as you get it. And if you have any questions, please call us at (305)504-8475. Please remember to CLICK THE SUBMIT BUTTON.