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Enter NPI # for Physician or Mid-Level Provider
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Please select Provider Group
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Registration


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."

REGISTRATION INSTRUCTIONS


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.

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List any Independent Physician Association (IPA) you are associated with.

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PRACTICE INFORMATION


Address/Tax
 
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Primary Contact    (Please enter the name of the contact who will complete your detailed practice demographics)
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PHYSICIAN INFORMATION


Click ADD to enter physicians
Physician NPI # Physician Name Physician Specialty Physician Contracts PhysicianContractsID PhysicianSpecialtyID ProviderExists RegistrationPhysicianID Select

DOCUMENT UPLOAD

   

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.

Drop your files here
OR
Select File:

Uploaded files :

    AGREEMENTS


    PARTICIPATION AGREEMENT
    View Document
    View Document
    (You must "View Document" to accept).
     Required

    MPACTMD SOFTWARE

    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.

    View Document
    (You must "View Document" to accept).

    REGISTRATION COMPLETION



        Signed By:

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    Please enter the sales representative name who assisted with this application.
    Please review the following information and click the Submit button below. Your information will be review and approved. You will be notified by email, when your submission has been approved.

    Provider NPI Provider Name Add to Provider Group/Contracts