Physician group applicationContinue an applicationContinue

1Group detailsIn progress · entity, addresses, officers
2DocumentsCertificate of formation or good standing and Professional liability (malpractice) certificate
3Review and submitThe network team verifies the group and invites your administrator

Step 1 of 3

Tell us about the group

All fields are required unless marked optional. You receive a reference and an access code to continue later.

Website

The physician group

The legal entity that employs or contracts the clinicians and holds their malpractice cover.

Legal nameTrade name (optional)Entity typeState of formationEINOrganizational NPIThe group's type 2 NPI, ten digits.Clinicians joining

Addresses

The registered address, and where mail and patients' records reach the group if those differ.

Registered address · streetRegistered address · suite or unit (optional)Registered address · cityRegistered address · stateRegistered address · ZIP code

The mailing address is the registered address.

Mailing address · streetMailing address · suite or unit (optional)Mailing address · cityMailing address · stateMailing address · ZIP code

The practice address is the registered address.

Practice address · streetPractice address · suite or unit (optional)Practice address · cityPractice address · statePractice address · ZIP code

Officers and contacts

The people a covered entity must name. One person may hold several of these roles.

Authorized signatoryAuthorized signatory · titleAuthorized signatory · emailPrivacy officerPrivacy officer · emailSecurity officerSecurity officer · emailRecords custodianRecords custodian · emailIncident contactIncident contact · emailIncident contact · phone

States the group serves

States where the group's clinicians hold, or are obtaining, a license. Licenses are verified per clinician after approval.

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You, and the group's first administrator

On approval the first administrator receives an email invitation to run the group's workspace. It may be you.

Your nameYour name · titleYour name · emailGroup administratorGroup administrator · email

I am authorized to apply on behalf of this physician group. I understand that joining needs an executed services agreement and business associate agreement, and that no clinician sees a patient until their credentials are verified. See the platform terms and privacy notice.

Next: upload the group's documents, then submit the application for review.

Bring your group into the network

Ambition Health provides the software. Medical groups on the network remain independent: your licenses, clinical judgment, malpractice cover and records stay yours. Brands reach your clinicians only under agreements you sign.

Where the network stands

Applications are open and the network team reviews each one. Prescriber verification and partner agreements are still being set up, so an approved group cannot see patients yet, and we do not promise a review time.

No patient information

This application asks only about the group. Do not upload anything that identifies a patient.