Action Center

All form fields are required.

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.

Required

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

Required

PRACTICE INFORMATION

Address/Tax

Required

Incorrect Format

Primary Contact (Please enter the name of the contact who will complete your detailed practice demographics)

Required

Incorrect Format

Have you Signed PPA Contract

Required

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

Select File:

Uploaded files :

AGREEMENTS

PARTICIPATION AGREEMENT

Please view, print and sign the TXCIN-ACO Paticipation Agreement. You can then upload the signed document in the DOCUMENT UPLOAD section above. View Document

I have read and accept the [PGName] Provider Participation Agreement terms & conditions. 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.

I have read and accept the mpactMD Access License Agreement, HIPAA BAA and Integration Addendum. View Document
(You must "View Document" to accept).

REGISTRATION COMPLETION

Please sign below

Signed By:

Required

I represent and have the requisite authority to execute these documents on behalf of the practice and/or physician affiliated with the practice, as applicable.

Required

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

Registration

PHYSICIAN REPRESENTATIVE INFORMATION

REGISTRATION INSTRUCTIONS

PROVIDER GROUP INFORMATION

PRACTICE INFORMATION

Address/Tax

Primary Contact (Please enter the name of the contact who will complete your detailed practice demographics)

PHYSICIAN INFORMATION

DOCUMENT UPLOAD

Uploaded files :

AGREEMENTS

PARTICIPATION AGREEMENT

MPACTMD SOFTWARE

REGISTRATION COMPLETION

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