Apply

Your application can be reviewed as soon as it’s complete.  We’ve included a handy application checklist below of necessary items.

• Completed and  Signed Online Application form
• Completed and Signed Physician Participation Agreement (PPA)
• Curriculum Vitae/Resume
• Copy of your CAQH Summary page
• Current MA state medical license
• Current Federal DEA Registration Certificate – To apply for a DEA registration or to obtain a copy of your certificate, contact the Regional Office of the Drug Enforcement Administration, 50 Staniford Street, Suite 200, Boston, MA 02114 or call (617) 557-2200.
• Current State Controlled Substances Certificate – To apply for a Mass. Controlled Substances number or to obtain a copy of your certificate, contact the Department of Public Health, Division of Food and Drugs, 99 Chauncy Street, Boston, MA 02111 or call (617) 983-6700.
• Current Professional Liability Insurance Facesheet – A copy must be obtained from your individual carrier and/or your agent and must have your name on it, the dollar amount you are covered for, and the dates your malpractice insurance coverage is effective.
• Copy of Board Certification or Board Eligibility Letter (if provider is not yet Board Certified, or going through a recertification)
• Valid Photo ID or Passport
• Copy of W-9 (for new practices Only)
• Collaborative Agreement (For Advanced Practitioners Only)