MD-Match — NP / PA Intake

01 Contact & Credentials

First Name *

Last Name *

Email *

Phone *

Credential *

Specialty *

Please specify your specialty *

02 What Brings You to MD-Match?

What brings you to MD-Match? *

Looking to start my own private practice Joining a group practice Switching to a new collaborator

What is the reason for switching?

03 Your Practice

How many years of experience do you have as an NP/PA? *

Practice setting *

In Person Virtual Both

Patient population (select all that apply)

Children and Adolescents Adults Geriatrics

How many hours per week are you working, or do you plan to work? *

Practice Site Address (Required for Texas NPs/PAs)

Ideal Start Date for Collaboration *

When do you plan to see your first patient? *

I am already seeing patients Within 2 weeks Within 4 weeks Within 2 months Within 3 months I still need an extensive amount of credentialing and expect to wait longer than 3 months to see my first patient

State(s) of practice *

0 selected

04 Background Screening

We verify every provider and every physician in our network. These four questions are part of that check, and a “yes” doesn’t disqualify anyone — it just means we’ll talk it through.

Have you ever had a board action taken against your license? *

Yes No

Please describe

Have you ever had your license suspended or revoked? *

Yes No

Please describe

Have you ever had a DEA action taken against you? *

Yes No

Please describe

Have you ever had a malpractice judgment or settlement against you? *

Yes No

Please describe

05 How Did You Hear About Us?

Referred by (optional)