$1500/month minimum for physician/practice collaboration Please 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? *Yes No Listing on clinic or APC malpractice Certificate of Insurance (COI) is required - do not continue with requests if unable to satisfy this requirement Request 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 DONPPACPP RN LPN MAMBA None of the above Location requesting services *North Carolina South Carolina Virginia Telehealth/Telemedicine Only or RemoteOther, not listed above Briefly state your request in consulting services and any other relevant information below. *CommentSubmit
