NP Collaboration / Autonomous Form

NP Collaboration / Autonomous Form
Grow Therapy requires all Nurse Practitioners to maintain an active Collaborating Agreement with a physician for each state they practice, unless state regulations permit Full Practice Authority.
If you have questions about state Collaborating Physician requirements, how to obtain autonomy, or to see if you qualify for independent practice, see our Guide for Collaborative Agreement Requirements at Grow.
Legal Name*

First NameLast Name
Email*
Please enter the email on file with Grow Therapy
Please select from the following:*

I have an active Collaborative Agreement or Proof of Autonomy to provide.I am in the process of obtaining a Collaborative Agreement and do not yet have one to provide.
CALC - NP Collab Form - Agreement not Uploaded

Yes
In which state(s) do you have an active license and would like to work with Grow?*

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
I have autonomous practice in Massachusetts*
If "Yes" you will receive an attestation form to complete your application
I have autonomous practice in Nebraska *
If "Yes" you will receive an attestation form to complete your application
I have autonomous practice in New York *
If "Yes" you will receive an attestation form to complete your application
I have autonomous practice in South Dakota *
If "Yes" you will receive an attestation form to complete your application
I have autonomous practice in Vermont *
If "Yes" you will receive an attestation form to complete your application
If you are licensed in a state that requires a collaborative agreement to practice, please upload your active collaboration agreement (dated within the last 12 months). If you have full practice authority, please upload proof of autonomy here.

Cancelof
Date

MonthDayYear
Date
Name of collaborating physician
Please enter your collaborating physicians NPI number
Some of the insurances we work with require this for credentialing. Please check with your physician or look this up on the NPI registry to avoid delays with your applications
Please enter your collaborating physician’s License Number in the state(s) where the collaborative agreement is active
Calc - Hybrid/Collab/Autonomous
Thanks for letting us know that you're still in the process of obtaining your Collaborating Physician Agreement.

Please submit this form and we will email you a link to provide us with your Collaborative Agreement at a later time!

Your information will not be sent to Grow until you click "Submit" below!
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