MD-Match
Connecting NPs & PAs with Collaborating Physicians Nationwide
Physician Intake Form Form MD-NP-01 · Confidential Version 2026
Complete this brief form so we can match you with Nurse Practitioners across the country. We focus on your licensure footprint, DEA registration, and collaboration availability — the details that matter most for a compliant match.
01 Personal & Credentials Basic Information
02 Licensure, Collaboration & DEA Collaboration-Required States Only
Only states where NPs are legally required to have a collaborating physician are shown below. States with full NP independent practice authority are excluded.
Licensed In *
States where you currently hold an active medical license
0 selected
Available to Collaborate *
States where you're open to entering a collaborative agreement
0 selected
Active DEA Registration
States where you currently hold an active DEA number
0 selected
03 Clinical Preferences Collaboration Comfort & Scope
Your answers help us match you with NPs whose practice scope aligns with your comfort level. There are no wrong answers — honesty ensures a better fit for both parties.
Are you comfortable collaborating with an NP who is prescribing controlled substances? *
Are you comfortable collaborating with an NP who is providing IV Ketamine treatment? *
Are you comfortable collaborating with an NP who is providing IM (Intramuscular) Ketamine treatment? *
Are you comfortable collaborating with an NP who is providing intranasal Ketamine (e.g., esketamine / Spravato) treatment? *
Are you comfortable collaborating with an NP who is providing TMS (Transcranial Magnetic Stimulation) treatment? *
Are you open to getting credentialed with insurance companies as requested by the NP? *
04 Legal & Board Standing Required Disclosure
Do you have any current, pending, or past disciplinary actions, investigations, or sanctions with any state Board of Medicine? *
Have you ever had a medical license suspended, revoked, or placed on probation in any state? *
Has your DEA registration ever been suspended, revoked, or voluntarily surrendered? *
Are you currently involved in any malpractice litigation? *
Disclosure of a past issue does not automatically disqualify you. All responses are reviewed confidentially by our team and evaluated in context. Omitting material information may result in removal from the platform.
05 One Last Thing
Fields marked * are required. All information is kept strictly confidential and is never shared publicly or sold. You will hear from our team within 3–5 business days.