Request a Collaborating Physician

Your information

Today's date *

First name *

Last name *

Email *

Mobile phone number *

NPI number *

State you live in *

Preferred method of contact *

Phone CallTextEmailAny

Has your license ever been suspended or have you ever been under a malpractice investigation? *

Yes No

Practice & specialty

Practitioner / clinician type *

Nurse PractitionerPhysician AssistantOther

What is your specialty? *

Describe other clinical services not listed above (provide detail so we can align physician scope)

Practice name (if you need a physician for a Job or DEA only, type "For Job" or "For DEA") *

Collaboration needs

Which state(s) are you seeking physician collaboration / medical director in? (SC matching may take longer) *

⚠️ Georgia (GA) is currently unavailable due to active state board regulation changes.

Is the physician required to be in a specific state? (Name the state or type "No") *

Required to be a specific specialty? (Psychiatry takes longer / costs more — name it or type "No") *

How soon do you need a collaborating physician? *

Are you seeking collaboration for a Job, Business, or DEA preparation? *

For Employment For my Business I am preparing for a Job or Business and need collaboration to obtain my DEA

If collaborating for your business, how long have you been in business?

Brief summary of your experience, specialty, and what you're looking for in a collaborating physician

Fee tier & add-ons

All quoted monthly fee tiers are bundled (physician compensation + platform + payment processing). Final pricing may vary by state and specialty. The $325/M tier is reserved for practitioners, in credentialing; with no active patients; no job, and is not available for SC, CA, FL, psychiatry, or stimulant prescribing. We are currently not supporting Georgia.

Select a fee tier that applies to your situation (FL, CA, SC, Psychiatrist not included in $325 tier) *

Psychiatrist • FROM $550/M • Minimal to High Oversight Primary Care / Non-Psychiatry • $465/M • Growth Phase – New/Early Practice (10-20 hrs/wk) I do NOT have any patients (<10 hrs/week) • $325/M × 3 Months, then From $450 • Launch Phase • Non-Psychiatry • 6-month minimum (excl. CA, FL, SC, or if prescribing CS) Primary Care / Non-Psychiatry • $565/M • Established Practice (21-30 hrs/wk) Primary Care / Non-Psychiatry • Full-Time / Higher Volume • 30+ hrs/wk • FROM $775/M

Add-on (non-psych collaborators) *

I will be Prescribing Stimulants +$125 (for up to 10/month). I will prescribe controlled substances but not stimulants (+$100) I will not prescribe any controlled substance I am seeking DEA registration but not prescribing yet

Add-on: will you need collaboration in more than one state? *

I do not need oversight in an additional State I need Minimal/Standard Oversight in another or other States (+$150/State) I need Moderate-High Oversight in another or other States (+$250/State)

🧩 Optional add-on services *

Credentialing/Payer Enrollment SupportBusiness Support/Start-Up/GrowthNot sure yet – I’d like to schedule a call (Please call us)Multi-State licensing Marketing/Web presence/Digital strategyNone

Logistics

Preferred start date *

If starting mid-month, your first invoice will include the fee for the remaining month and full fee for the following month.

How did you find us / who referred you? *

Please provide the practice or business address that will be used on the Collaborative Practice Agreement.

Address line 1 *

Address line 2

City *

Zip code *

State *

Upload your resume (PDF, DOC, DOCX) *Drag & drop or click to browse

Agreements

I agree to the Business Service Agreement and terms above *You agree not to bypass Wholesome Collaborations by directly engaging with physicians introduced through our platform during your engagement and for 24 months following termination. Violations may result in fees or loss of access.I understand and agree to the monthly billing policy *Collaboration fees are billed monthly and the first payment will be due immediately upon signing the agreement, and prior to receiving a copy of the agreement. Future payments are due on the 1st of each month, with a 10% late fee after the 3rd.

Start Your Collaborating Physician Match Request

Your information

Practice & specialty

Collaboration needs

Fee tier & add-ons

Logistics

Agreements