$1500/month minimum for physician/practice collaborationPlease enable JavaScript in your browser to complete this form.Request is for which of the following (Choose Below)? *Private practice owned by APC (NP or PA) or CPPCorporation Request (Clinic, Lab, or Other Facility)Other This Contact Form is intended for Supervision, Collaboration or Medical Directorship requestsThe minimum supervision/collaboration fee per APC or CPP is $1500 per month. Are you able to pay this minimum monthly fee? *YesNoListing on clinic or APC malpractice Certificate of Insurance (COI) is required - do not continue with requests if unable to satisfy this requirementRequest is for which of the following (Choose Below)? (copy) *Private practice owned by APC (NP or PA) or CPPCorporation Request (Clinic, Lab, or Other Facility)Name *FirstLastEmail *Credentials *MD or DONPPACPPRNLPNMAMBANone of the aboveLocation requesting services *North CarolinaSouth CarolinaVirginiaTelehealth/Telemedicine Only or RemoteOther, not listed aboveBriefly state your request in consulting services and any other relevant information below. *MessageSubmit
