Join our clinical team

Provider application.

Tell us about your credentials, service areas, and availability. Complete the field clinician application below, review your entries, and print or save a PDF for signature.

Complete here. Review. Print and sign.Entries stay in this page and are not sent to Apogee or Salesforce. They are not saved for a later visit. To submit your signed application and credential documents, call Provider Administration at 951-368-0428 for the approved method.

Based on the Field Clinician Application & Credentialling Form, Rev. 12/19. Current organization name: Apogee Health Solutions, PC. Social Security numbers and identity-document uploads are reserved for secure onboarding.

1. Applicant information

Fields marked * are required. Birth and demographic details are optional in this website form.

Last name *First name *Middle nameClinical designation / provider type *SexSex — self-description (optional)Date of birthBirth state / provinceBirth countryStreet address *City *State / territory *ZIP / postal code *Cellular phone *FaxEmail *

2. Professional credentials

Social Security numbers are not collected here. Provide them only through the approved secure onboarding process when requested.

Clinical license number *License state *License expiration date *Rendering NPIRendering PTANDEA number / permit (if applicable)EIN / business Tax ID (optional)

3. Professional liability insurance

Professional liability carrierPolicy numberPolicy expiration date

4. Service area and availability

Preferred areas / cities *

Choose each available day and enter a start and end time. Leave unavailable days unchecked. Times refer to the service location’s local time. A shaded bar shows the selected hours on a full-day timeline and is included in your printed application.

For overnight hours, split availability across two days. If your schedule varies, describe it below.

Additional availability details

5. Eligibility information

Answer every question. For any Yes answer, provide the question and relevant details below. Do not include patient names or patient records.

Have you ever been convicted of a felony in any state? *Have you ever had your license suspended or revoked by any state? *Has a Peer Review Committee ever cited you for violation of an ethical standard by a professional organization? *Have you ever had your malpractice insurance canceled? *Do you have any past or pending legal actions against you relative to your clinical practice? *Have you ever been dismissed from any employer relative to your clinical practice? *Have you ever had your narcotics license suspended or revoked? *

6. Prepare your documents

The source application lists the items below. Confirm which are applicable with Provider Administration. Document uploads are not available on this website. Use your secure onboarding invitation or the submission method provided by the office.

Social Security card
Driver license
Clinical license / certification
Professional liability insurance certificate showing coverage limits and dates
Curriculum vitae / résumé
Completed and signed W-9
ACLS / BCLS certification
DEA license / permit
Work permit and/or Green Card (if applicable)

7. Review and certification

I certify all statements to be true and correct and authorize the investigation of all statements contained in this application. I understand that misrepresentation or omission of facts is cause for dismissal. I understand that this is a declaration of intention and not a contract.

I have reviewed my entries and agree to the certification above. *

Print or save the completed application, then sign and date it. This checkbox does not replace your signature. Call Provider Administration for the approved submission method.

Closing or refreshing this page discards your entries. This application does not confirm acceptance, credentialing approval, or engagement with Apogee.

Provider application.

Your completed application