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Join the Access Healthcare Direct Network
Please fill out the form below to join the network. We will review the information and typically upload you to the Provider Directory and Employer Platforms within 1 week if you are approved.
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* Required
Email
*
Your email
What is your NPI number? (credential verification only)
Your answer
What is your Medical License Number and State ?
Your answer
Provider name & Practice name
*
Your answer
Practice Phone & Address
*
Your answer
Practice Website
*
Your answer
Email Address
*
Your answer
Do you want to join the Access Healthcare Direct Network of Direct Primary Care Practices?
*
Yes
No
Would you like us to market to employers and patients on your behalf through our phone apps and DPC Doctor finder, the Accresa platform, GoMD/FlexPerx and our website.
*
Yes
No
What is the minimum monthly fee you will accept per person for Direct Employer Contracts? (You can charge any amount you like but Employers frequently search for practices based on this filter)
50
60
65
75
Other:
Clear selection
Are you a Direct Primary Care practice by the current accepted definition and not planning on billing any insurance companies or Medicare?
*
Yes
No
Are you currently Board Certified or Eligible?
Yes
No
Other:
Clear selection
Have you ever had a malpractice claim?
*
Yes
No
Please indicate in this box common services that you include in your DPC membership at no additional charge (office visits, physicals, common labs etc)
Your answer
How much capacity do you have for new patients?
1-199
200-499
500-799
800-1000
Clear selection
What is the average monthly fee you will be charging?
$25 - $59
$60 - $65
$66 - $85
$86 - $150
Other:
Clear selection
Do you agree to the terms and policies below: If so type your name here to sign electronically
*
Your answer
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