CURRENT ACEP/SEMPA Group Billing Program participants
Please enter any information that has changed in the past 6-12 months with the form below.
Are you interested in joining one of our Group Billing Programs? Please download our ACEP and SEMPA group benefits and enrollment forms.
Download PDF Forms
ED Physician Group Information
Physician Assistant and Nurse Practitioner
Number of Physician Assistant Employed
Who is responsible for training PA and NP?
Who is responsible for hiring and managing PA and NP?
If other, please provide additional information/contact information if different from above
Group Coordinator Information
Medical Director Information
Hospital(s) Serviced by Group
If you have more than 5 Hospitals to list, please email a detailed list (Name, State, Zip) to Kelley Govan or fax the list to 972.534.1579 (the fax should be to the attention of Kelly Govan). For Email attachments, we only accept PDF, Word, or Excel documents.
Please select one of the following
These questions are for internal purpose only and not for display
Current/Enrolling ACEP Group Billing Participants and SEMPA 100% Club ONLY
If you have a physician, physician assistant or nurse practitioner member changes to your current participating group roster, please include the providers first and last name, ACEP or SEMPA ID (if applicable) and their email address in the fields below. If you have additional questions/requests please enter it below:
If you have more than 5 participants, you will have the opportunity to attach your list on the next page after you submit this form.