All form fields are required.
PHYSICIAN REPRESENTATIVE INFORMATION
If you received an invitation code from an APEX member physician, please enter the code or verify the pre-filled code and physician name below."
Please complete the following information about your practice and physicians. After review of your registration, signed agreements will be sent to the e-mail address provided below.
PROVIDER GROUP INFORMATION
Select the APEX Division for your area.Required
List any Independent Physician Association (IPA) you are associated with.Required
Primary Contact (Please enter the name of the contact who will complete your detailed practice demographics)
|Physician NPI #||Physician Name||Physician Specialty||Physician Contracts||Select|
If you have signed a paper Provider Group Agreement or Carrier ETP forms, please upload here.
If not, electronic agreement(s) will be created from your submission information.
Uploaded files :
PARTICIPATION AGREEMENTView Document
mpactMD is the software utilzied by the APEX CIN to manage practice demographics, data aggregation, analysis and reporting. In order to participate with APEX, please review and accept the mpactMD Access License Agreement, HIPAA BAA and Integration Addendum.