Provider Partner Intake | CareMatch Pros by AMS

CareMatch Prosby AMS Return to website

1 Organization and contact

Public organization nameLegal business namePrimary contact nameContact titleBusiness emailBusiness telephoneWebsite OptionalYear established

Business structureHeadquarters state

Business address

2 Services and coverageServices offered Select all that applyCounties, cities, ZIP codes, or mileage radius servedService delivery model

3 Compliance and readiness

License or certification statusLicense or certification identifiers Do not upload documents hereNPI number If applicableProfessional liability insuranceBackground-screening processAccepting referrals now?

Current capacity and expected availability

4 Qualified-lead criteriaPopulations served Select all that applyMinimum financial or payment requirementsEligibility and admission criteriaExclusions or automatic disqualifiers

Typical response timePreferred lead delivery

Primary lead-contact instructions

5 Partnership acknowledgmentAdditional information Optional

I am authorized to submit this application for the organization.I certify that the information provided is accurate and will notify CareMatch Pros when licensing, capacity, pricing, or eligibility criteria change.I authorize CareMatch Pros to verify business, licensing, insurance, and credential information before activation.I understand that approval and lead delivery are not guaranteed, provider information remains subject to review, and separate partnership or lead-fee terms may apply.

Do not submit Social Security numbers, banking details, client records, or credential documents through this form.