Service Provider Application

Basic Information

Contact & Services

Documents

Step 1 of 3

Tell us about your healthcare institution and what makes it special

Organization Name

Enter the official name of your healthcare institution

Brand Name

Marketing or brand name (if different from organization name)

Institution Type

Type of healthcare facility

Establishment Year

Year the institution was established

Description

Provide a comprehensive overview of your healthcare services and specialties

Website

Institution's official website

Main Phone

Main phone number

Emergency Phone

Emergency contact number

Where is your healthcare facility located?

Street Address

Complete street address of your facility

City

State / Province

Country

Country where your facility is located

Postal Code

Postal or ZIP code

Please review and accept our registration agreement to proceed

Platform Services:

FAH forwards patient applications and provides access to applicant information

Provider Responsibilities:

Maintain accurate information, transparent pricing, and comply with data protection laws

Fees & Data Protection:

Subscription and commission fees apply. Full HIPAA, GDPR, KVKK compliance required

By checking this box, I confirm that I have read, understood, and agree to be bound by all terms and conditions outlined in the agreement.

Step 1 of 3 - Basic Information

Please accept the agreement to continue