Membership application

Membership Application

Thank you for your interest in becoming a member of Access, the Health and Wellness Association. If you are ready to complete an application, please begin by telling us the type of provider that you are.
What type of provider are you?
Holistic
Conventional
Provider and Practice Information
Required Disclosures
Licensure:
Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?
Yes
No
Affiliations:
Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (Including HMOs, PPOs, or provider organizations such as IPA’s PHOs)?
Yes
No
Medicare. Medicaid or other Governmental Program Participation:
Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs.
Yes
No
Select your desired membership level
I accept Terms & Condition *

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By qualifying for membership, you can lever all aspects of Access to propel your practice with virtual care, social media and more to drive new patient acquisition and existing patient value.

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