Apply for access - Comprehensive Biosciences

Apply for provider access

Comprehensive Biosciences works with licensed providers. Tell us who you are and we will take it from there. Everything marked with an asterisk is needed.

Who this application is for

This decides what we ask below, and what you confirm at the end.

Registering as * Myself I am a single provider applying for access in my own name. Nobody else needs access. My practice I am the provider responsible for a practice, and colleagues there will need access under my NPI or license.

Who you are

The person we will be speaking to.

First name *

Last name *

Email Optional. It is the quickest way for us to come back to you.

Phone Needed if you have not given an email address, so we have a way to reach you.

Your credentials

We need either your NPI or your professional license number. One of the two is enough, and giving both helps us review faster.

NPI number Ten digits. We check the format as you send it and confirm it against the national registry when we review your application. Leave it blank if you are giving a license number instead.

License type Needed with a license number.

Professional license number Needed if you have not given an NPI.

If you chose Other, what kind of license is it?

Issuing state

Expires

Your practice

The practice this application is for.

Practice or clinic name *

Legal name of the practice * The name on the practice paperwork, when it is not the name above. We use it on the agreements we send you.

Street The address is optional, and giving it saves us a phone call.

City

State

ZIP

How you heard about us

We ask everybody, and we do read the answers.

Who referred you to Comprehensive Biosciences? *

Anything else we should know

Attestation

What you confirm depends on the choice you made at the top of this form.

If you are registering as yourself

I confirm that the information I have given is accurate and complete, that I am a licensed healthcare provider applying for access in my own name as a single practitioner, that this account will be held under my own NPI or professional license, and that Comprehensive Biosciences may verify the credentials I have given with the issuing authorities.

If you are registering your practice

I confirm that the information I have given is accurate and complete, and that I am a licensed healthcare provider authorized to apply on behalf of the practice named above. I understand that this account is held under my NPI or professional license, and that everything submitted to Comprehensive Biosciences through it, including anything submitted by a member of my staff whom I have invited to the account, is submitted under my credentials and is my professional responsibility. I am responsible for deciding which people at my practice are given access to this account and what they may do on my behalf, and I will tell Comprehensive Biosciences without delay when somebody should no longer have access. Comprehensive Biosciences may verify the credentials I have given with the issuing authorities.

Our team reviews every application before access is granted.

Need help? Contact Info@comprehensivebiosciences.com