Please complete the application below to practice telemedicine on Maven, serving the community during this public health crisis.  Our team is working hard to process applications as fast as possible. Be on the lookout for additional information shortly.

Please email providers@mavenclinic.com with any questions.

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* 1. Full name (as reflected on your medical license)

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* 2. Email address (please note this address will be used to set-up your Maven account)

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* 3. Phone number:

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* 4. Please list all languages (other than English), in which you have clinical proficiency:

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* 5. Do you have access to an iPhone or iPad (please note either device is required to practice on Maven)

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* 6. Primary Profession:

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* 7. Please list any additional areas of expertise:

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* 8. Education:

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* 9. Degree Type:

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* 10. Years of professional experience:

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* 11. Are you currently licensed to practice your profession?

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* 12. Medical License:

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* 13. Please complete for any additional medical license you hold:

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* 14. Please complete for any additional medical license you hold:

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* 15. Please complete for any additional medical license you hold:

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* 16. If you hold any temporary or emergency licenses, please list here:

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* 17. Are you board certified?

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* 18. Would you like to prescribe on Maven?

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* 19. If yes, please upload a government issued photo ID here and complete all questions below:

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
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* 20. Date of birth:

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* 21. Address (shared with Pharmacies)

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* 22. Phone number (shared with Pharmacies):

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* 23. NPI Number:

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