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* Required fields. All other fields are optional.

Organization Information

Tell us about your primary location.

Legal Business Name *

Doing Business As (DBA)

Primary Location Address *

City *

ZIP Code *

Phone Number *

Website

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Practice Details

Tell us about your organization so we can identify the most relevant contract opportunities.

Primary Specialty or Practice Type

DEA Number

Number of Locations

Number of Providers

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Additional Locations

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Primary Contact

This person will receive enrollment updates, contract information, savings opportunities, and other MediGroup member communications.

First Name *

Last Name *

Title *

Email *

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Current Distributor Information

MediGroup works with your current distributor to identify eligible contracts, pricing opportunities, and account alignments. You do not need to change distributors to participate. Please provide as much information as you have available.

Primary Medical Distributor

Distributor Representative Name

Distributor Representative Email

Distributor Account Number (if known)

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Agreement

Review and authorize participation in MediGroup.

Signer is the same as the Primary Contact

Signer First Name *

Signer Last Name *

Signer Title *

Signer Email *

I Agree to the Terms and Conditions of the MediGroup Participation Agreement *

Submit Participation Agreement