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Your Information

First Name:*

Last Name:*

Gender:*

Male
Female

Practice / Clinic Name:*

Practice / Clinic Address:*

Street Address City State ZIP Code

Is your practice located in a home office, gym or spa facility?

Yes
No

Practice / Clinic E-mail:*

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Provider E-mail:*

Enter Email Confirm Email

Please enter the provider's direct, unique e-mail address. Applications must be sent to a unique e-mail address and cannot be sent to generic addresses, such as info@ or clinic@.

Practice / Clinic Phone:*

Practice / Clinic Fax:*

Discipline(s):*

Chiropractic
Naturopathic Medicine
Acupuncture
Massage Therapy

Length of time in practice:*

Preferred application delivery method:*

Preferred contact method:*

E-mail
Phone
Mail

What type of computer/device will you be using to complete your credentialing application?*

Windows-based
Apple iOS-based (iPhone, iPad, iMac laptop or desktop, etc.)

Hidden

How were you referred?*

Do you offer evening hours? (Mon-Fri after 5 pm)*

Yes
No

Do you offer weekend hours? (Saturday and/or Sunday)*

Saturday only
Sunday only
Saturday and Sunday
No weekend hours

How many hours do you practice per week?*

Do you practice any unique techniques?*

Yes
No

If Yes, please list unique techniques here:

Do you have any board certifications?*

Yes
No

If Yes, please list your board certifications:

Do you or any of your office staff speak any languages other than English?*

Yes
No

If Yes, please list languages spoken other than English:

Are you purchasing a CHP provider's practice?

Yes
No

Name

Prefix First Middle Last Suffix

CHP Provider Discipline

Chiropractic
Naturopathic Physician
Acupuncturist
Massage Therapist/Practitioner

Practice/Business Name

Practice/Business Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Practice/Business Phone

Sale of Practice (SOP) Effective Date

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Thank you for your interest in joining our network of high-quality integrative healthcare providers.

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