All form fields are required.
ACO Registration
PHYSICIAN REPRESENTATIVE INFORMATION
If you received an invitation code from [PGName] 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.
RequiredList any Independent Physician Association (IPA) you are associated with.
RequiredPRACTICE INFORMATION
Address/Tax
Primary Contact (Please enter the name of the contact who will complete your detailed practice demographics)
PHYSICIAN INFORMATION
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.
Uploaded files :
AGREEMENTS
PARTICIPATION AGREEMENT
View Document(You must "View Document" to accept).
MPACTMD SOFTWARE
mpactMD is the software utilized by [PGName] to manage practice demographics, data aggregation, analysis and reporting. In order to participate with [PGName], please review and accept the mpactMD Access License Agreement, HIPAA BAA and Integration Addendum.
(You must "View Document" to accept).
REGISTRATION COMPLETION
Signed By: