503A Practice Enrollment

Begin a new practice relationship

Share the primary details about your practice and operating model. Our team will review the request and guide you through the appropriate onboarding steps.

This form is intended for provider and practice enrollment only. Do not submit patient-specific health or prescription information.

Begin Enrollment

Before you begin

Use business information

Provide your primary professional contact and practice location.

No patient PHI

Do not enter patient names, diagnoses, prescription details, or insurance information.

Enrollment is reviewed

Submission begins the process but does not automatically create or approve an account.

Practice Enrollment

Tell us about your practice

This form begins the enrollment review for a new provider or practice relationship. It does not request patient information or replace the formal account documentation that may follow.

What happens next

Initial review

Our team reviews your practice profile, location, and operating model.

Enrollment follow-up

The appropriate team follows up regarding documentation and next steps.

Account readiness

Setup proceeds after required information and eligibility are confirmed.

Pharmacy or facility buyer?

This form is intended for provider and practice enrollment. Pharmacies, hospitals, clinics, and facility buyers seeking 503B support should begin with the buyer pathway.

View the 503B buyer pathway

New practice request

Practice enrollment

Required fields are marked with an asterisk.

1 Primary contact Tell us who will coordinate the enrollment process.

First name Last name Email Phone Your role

2 Practice profile Provide the primary location associated with this request.

Practice or company name Practice website Street address Suite or unit City State ZIP code

3 Operational snapshot Help us understand how your practice currently serves patients.

Which best describes your organization?

We see patients primarily in office We see patients in office and through telehealth We use or operate through a telehealth network We operate a wellness or specialty practice Another provider or practice model

4 Areas of interest and notes Optional details help us prepare for the first conversation.

Treatment areas or medications of interest Additional information

5 Final details Complete the request and submit it for review.

How did you hear about us? I confirm that this form contains no patient-specific protected health information and understand that submission begins an enrollment review but does not guarantee account approval or service availability.

Do not submit patient information

Do not include patient names, prescription details, diagnoses, dates of birth, insurance information, or other PHI.

Our team will review the request and contact you regarding the appropriate next step.