Medical Director Request Form

📌 Before You Begin

Thank you for choosing Wholesome Collaborations. This form will help us understand your business and state-specific needs so we can identify an appropriate match for you. You may be asked to sign in or create an account when you submit, so we can track your request.

To begin: a $99 intake deposit is required.

• The intake deposit is fully refundable if you cancel your request before our matching process begins. Once physician outreach is initiated or an introduction is made, the deposit becomes non-refundable to cover administrative and vetting costs.
• Remaining onboarding balance due only after match approval

Onboarding fees if matched:

• First state: $300 less deposit
• Additional state, same NP/business/physician: $125
• Additional state, new NP/business/physician: $300

Important: Some states have CPOM laws that may require an MSO structure with a licensed physician.