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Become A Total Access Medical Physician

Fields marked with an asterisk (*) are required.

*First Name:
  
*Last Name:
  
*
   MD DO
*Email Address:
  
Office Address:
  
Office City:
  
Office State:
  
Office Zip:
  
Office Phone Number:
  
Fax Number:
  
Cell Phone Number:
  
*
  1. Practice Description:
  
*
  1. Board Certifications:
  

If yes, please specify:
*
  1. # Of Active Charts (Per Doctor):
  
*
  1. Estimated Payor Mix:
   % Medicare
% PPO 
% HMO
*
  1. # Of Years In Practice:
  
*
  1. # Of Years In Current Office Location:
  
  1. Average # Of Patient Office Visits Per Day:
  
  1. Average # Of Hospital Visits Per Day:
  
  1. Average # Of Hours Spent In Office Per Day:
  
  1. Total # Of Days In Office Per Week:
 
  1. Hospital Staff Privileges:
 
  1. Top 5 Zip Codes (Or Towns) Of Patients:
  
  1. List All Awards, Hospital, Community Committees, And/Or Community Recognition:
 
  1. Preferred Method Of Contact:
 
  1. Would You Like To Subscribe To Our Newsletter?
 
  1. Comments:
  
  1. How Did You Hear About TAM?
  
   

 
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