Getting Started

Congratulations on your decision to apply to become an MDVIP affiliated physician!

Your choice to pursue becoming an MDVIP physician shows your deep commitment to your patients and their care, and to helping them to live the best, healthiest life possible.

Start on the pathway today to practicing medicine the way you dreamed you would when you were in school. Let us show you how to receive the professional satisfaction, personal life balance and financial rewards that you deserve based on your years of education, experience and excellent care you provide to your patients.

Please complete the information below and a member of our team will contact you to discuss your becoming an MDVIP affiliated physician.

  = Required Information

	Last Name
	First Name	MI
	Primary Specialty	Cardiovascular Disease Endocrinology Family Practice General Practice Geriatrics Internal Medicine Nephrology Obstetrics/Gynecology Pediatrics Pulmonary Diseases Rheumatology Other
	Secondary Specialty	Cardiovascular Disease Endocrinology Family Practice General Practice Geriatrics Internal Medicine Nephrology Obstetrics/Gynecology Pediatrics Pulmonary Diseases Rheumatology Other
	Practice Name
	Practice Environment	CommunityHospitalNursing HomeOther
	# of Doctors in Group	Solo    2-3    4-6    >6
	Years in Practice
	Years Practicing in Community
	Physician Relationship	MSO Owned by Hospital Employee
	Number of Offices
	Average # of Patients seen per day	<10    11-15    16-22    >23
	Practicing Hours (i.e. 8-5)	Mon Tue Wed Thu Fri Sat
	Practice Setting	Full Time    Other
	Number of Active Patients	<10001000-20002001-3000>3000
	Hospital Affillation
	Have you heard about MDVIP?	YesNo
	How did you hear about us?	Physician Patient MDVIP Employee Mail Article Advertisements TV Web / Internet Other
	Board Certifications	YesNo
	Are you accepting new patients?	YesNo
	Medical School
	Year of Graduation
	Residency Program
	Patient Insurance (%):	Medicare  PPO  POS        HMO             HMO Medicare        Cash
	DOB (Year)	1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
	Address
	City
	State	AE AK AL AP AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
	ZIP
	Email Address
	Office Number	( )- -
	Fax Number	( )- -
	Cell Phone	( )- -
	Preferred Contact Method	Office Cell Email
	Get the Newsletter
	MDVIP HIPAA	I have read and agree to MDVIP HIPAA
	MDVIP Confidentiality	I have read and agree to MDVIP Confidentialty

Privacy

MDVIP supports information privacy protection. Our first priority is to respect your privacy and we will never share, sell or release any personal information (including your email address) to advertisers or any other parties, or use your personal information for any other purpose, without your permission.