PatientIQ Registration Request

Practitioner Registration for PatientIQ (PRO platform)

This information is essential for PatientIQ to load you onto the platform and for you to be eligible for MIBAC participation. It will be shared only with the MIBAC Coordinating Center and PatientIQ. A Business Associate Agreement (BAA) will be sent by PatientIQ for HIPAA compliance.

Name*
First Last
Individual NPI
Professional Designation
Email*
Contact Number
Legal Practice Name
Public-facing practice name
Physician Organization
Please upload practice logo here
Accepted file types: jpg, jpeg, png, gif.
Email
This field is for validation purposes and should be left unchanged.

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Practitioner Registration for PatientIQ (PRO platform)

Address

313.874.2722

[email protected]