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Provider Network

Provider Network Application

We're extending the platform attorneys already trust across the full medical side of a personal-injury case. Apply below and our network team will follow up.

This application takes a few minutes. Only a handful of fields are required — complete what you can now, and our team will collect anything else during onboarding. Fields marked with an asterisk (*) are required.

01Organization Information
02Primary Contact
03Billing & Settlement Contact
04Business Location
05Services Offered
Select all that apply
06Personal Injury Experience
Currently serve PI patients?
Work under Letters of Protection?
Estimated PI cases per month
07Network Participation
What are you interested in?
08Technology & Integration
IT resources available?
09Compliance & Security
HIPAA policies in place?
Cyber liability insurance?
Able to sign a Business Associate Agreement?
Reportable security incident in last 24 months?
10Payment Information
Preferred payment method
11Documents You Can Provide
Check the documents you can supply during onboarding
12Provider Profile
Accepting new PI patients?
Offer telehealth?
13Certification

We’ll only use this to evaluate your application and contact you about the provider network.

Take medication funding off your plate

Register your firm today. Your first case can be funded this afternoon.

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