Practice intake

Register a practice

Complete the onboarding intake for your organization. A Meduvo SuperAdmin must verify the BAA and eSign compliance requirements before any PHI access is opened.

Tell us about your practice

Provide the basic information we'll use to set up your organization.

Practice Name *

Legal Business Name * Same as practice name

Practice Type *

Specify Practice Type *

Organization NPI (optional)

Operational Timezone *

Website (optional)

Estimated Monthly CoCM Patients *

An estimate is fine. This helps us plan your implementation.

Contact and location

Tell us who should coordinate onboarding and where the practice operates.

Primary Contact

First Name *

Last Name *

Job Title / Role *

Specify Role *

Contact Email *

This should be the primary onboarding and implementation contact.

Direct Phone *

Primary Practice Location

Practice Phone * Same as primary contact phone

Fax (optional)

Address Line 1 *

Address Line 2 (optional)

City *

State *

ZIP Code *

Tell us about your CoCM program

This information helps us configure your onboarding experience.

Current CoCM Status *

Specify CoCM Status *

Current EHR / EMR *

EHR / EMR Name *

EHR Integration Needed? *

Yes No Not sure

If yes or not sure, implementation will handle technical details securely later.

Number of PCPs *

Number of Behavioral Health Care Managers *

Psychiatric Consultant Status *

Already have a psychiatric consultant Will add one during onboarding Need assistance / not yet arranged

Approximate Eligible Patient Population (optional)

An estimate is acceptable.

Target Go-Live Date (optional) Not sure yet

Implementation Notes (optional)

Tell us about goals, workflow, integration requirements, timeline, or anything our implementation team should know. Please do not include patient names or other protected health information.

/2000

Review and submit

Review your practice information and complete the required acknowledgements.

Registration Summary

Practice

Practice name
Legal name
Type
Organization NPI
Timezone
Website
Monthly CoCM estimate

Primary Contact

Name
Role
Email
Direct phone

Location

Practice phone
Fax
Address

CoCM Program

CoCM status
EHR / EMR
EHR integration
Team
Psychiatric consultant
Eligible population
Target go-live

Authorized Representative

Authorized Representative Name *

Title / Role *

I confirm that I am authorized to register this practice and submit this information on its behalf. *

Compliance Requirements

Business Associate Agreement
We understand that a Business Associate Agreement (BAA) must be executed and verified before the practice can be activated. *

eSign & Compliance Documentation
We understand that required eSign and compliance documents must be completed and verified before staff members can access protected health information (PHI). *

By submitting this registration, you confirm that the information provided is accurate and agree to the applicable Terms of Service and Privacy Policy. These acknowledgements do not establish HIPAA compliance or activate PHI access.