Licensing · Application

Apply to become a Life Spark Certified Survivorship Practice.

Short application — under 5 minutes. We review within 2 business days and send the Master License Agreement and Order Form if it's a fit. Not a franchise. No FDD.

Pick a tier

Prescribing clinician seats

About you

Full name *Work email *PhoneBilling email

About your practice

Practice or organization *Practice NPI (optional)Primary stateActive survivors served

Eligibility

Check every item that is true today. Missing items don't automatically disqualify — we'll flag gaps on the review call.

I already operate a licensed medical or nursing practice.My prescribing clinicians hold active licenses in the states we serve.Practice carries current medical malpractice coverage.Practice has an existing HIPAA compliance program (P&Ps, training, breach plan).Practice has an EHR (Epic, Athena, eCW, Cerner, or equivalent).We have or can build referral relationships with local oncology centers.Willing to offer a cash-pay survivorship membership alongside insurance billing.Willing to sign a Business Associate Agreement with Life Spark.

Anything else we should know?

This is a licensing inquiry, not an offer. Final terms in the Master License Agreement and Order Form. No PHI over this form.