Partner Application

Apply to launch your white-label peptide wellness program. We review all applications within 48 hours and schedule a call with qualified practices.

Practice Info

Provider Details

Program Setup

Legal Review

Submit

Step 1 of 5

Your Practice

Tell us about your practice. All fields marked with * are required.

Practice Name *

Practice Owner / Director *

License Type *

Florida License Number *

Practice Address *

City *

State *

ZIP *

Primary Phone *

Primary Email *

Practice Website

Years in Practice *

Number of Active Patients *

Number of Locations

Step 2 of 5

Provider Details

Tell us about any licensed healthcare providers on your team. This helps us structure the right clinical arrangement.

Does your practice employ or contract with a licensed NP or PA? *

NP/PA Full Name

Florida License Number

License Type

License Expiration

Does this provider have any active restrictions, probation, or disciplinary history?

Does your practice have any history of AHCA actions, investigations, or sanctions?

Has your practice or any owner been excluded from Medicare/Medicaid programs?

Does your practice currently carry malpractice insurance? *

Step 3 of 5

Your Program

Tell us how you envision your branded wellness program. This helps us configure your white-label setup correctly.

Your Program Name *

This name will appear on your patient portal and medication packaging

Planned Program Price (per month)

You set this — we charge a fixed infrastructure fee

Select your Partner Tier *

Starter

$165/patient

Up to 25 patients

Growth

$150/patient

26–75 patients

Scale

$135/patient

76–150 patients

How many patients do you realistically expect to enroll in the first 90 days? *

Which patient populations does your practice primarily serve? (select all that apply)

Adults 35–55 focused on performance and recovery Adults 45+ focused on longevity and anti-aging Patients seeking weight management support Athletes and active adults Patients with chronic pain or musculoskeletal conditions General wellness and preventive health

How did you hear about the MyTelePep Partner Program?

Anything else you'd like us to know about your practice or goals?

Step 4 of 5

Legal Acknowledgments

Please review and acknowledge the key legal terms governing the partner relationship. Full document links are provided for your attorney's review.

Corporate Practice of Medicine (CPOM)

I understand that under Florida law, my chiropractic practice entity cannot own, control, or share in the profits of the practice of medicine. The MyTelePep partner arrangement is structured as a Management Services Organization (MSO) in which my practice provides non-clinical wellness program management services. All clinical decisions are made exclusively by TeleEMC's licensed providers. My practice earns a business margin on non-clinical services, not a share of medical revenue.

Read full CPOM compliance documentation →

I understand and acknowledge the CPOM structure of this arrangement. I will obtain independent Florida healthcare counsel review before executing the Management Services Agreement.

Anti-Kickback Statute

I understand that the Infrastructure Fee paid to TeleEMC is compensation for defined Management Services only and is not tied to the volume or value of patient referrals or prescriptions. I will not enter into any arrangement that ties my compensation to referral volume, prescription quantity, or any other metric that could constitute a kickback under federal or Florida law.

I understand that no compensation I receive through this program is tied to referral volume or prescription value, and I agree not to create any such arrangement.

Clinical Independence

I understand that TeleEMC's licensed providers exercise independent clinical judgment. I will not direct, influence, or interfere with any provider's clinical decisions, prescribing practices, or patient care recommendations. All clinical patient questions will be referred immediately to TeleEMC's clinical team.

I understand that my practice has no authority over clinical decisions and I will not attempt to direct, influence, or restrict TeleEMC providers' clinical independence.

HIPAA and Patient Data

I understand that I will be handling Protected Health Information of enrolled patients and that I must execute a Business Associate Agreement with TeleEMC before any patient data is shared. I will maintain appropriate administrative, physical, and technical safeguards for all PHI.

I understand my HIPAA obligations as a business associate and will execute a BAA with TeleEMC before any PHI is shared.

Compounded Medication Disclosure

I understand that compounded peptides are not FDA-approved drugs and have not been evaluated by the FDA for safety or efficacy. I will not make any claims to patients that imply FDA approval, guaranteed results, or safety profiles that are not supported by TeleEMC's approved patient education materials.

I understand that compounded peptides are not FDA-approved and I will only use TeleEMC-approved messaging when discussing the program with patients.

Management Services Agreement

I understand that this application does not constitute execution of the Management Services Agreement. The full MSA will be provided for my independent legal review before execution. I commit to having Florida healthcare counsel review the MSA before signing.

Review Management Services Agreement template →

I understand this application does not bind me to the MSA. I commit to obtaining independent Florida healthcare counsel review of the Management Services Agreement before execution.

Step 5 of 5

Review & Submit

By submitting this application, you are requesting a partnership review call with the MyTelePep Partner team. This application does not create a binding agreement.

Application Certification

I certify that all information provided in this application is accurate and complete to the best of my knowledge. I understand that misrepresentation of any material fact is grounds for immediate disqualification and termination of any subsequent partnership arrangement. I understand that submitting this application does not guarantee acceptance into the partner program.

Full Legal Name (typed) *

Title / Role *

Date

Electronic Signature *

Sign HereClear

Best time for our follow-up call

✅

Application received.

Thank you for applying to the MyTelePep Partner Program. Our team will review your application and reach out within 48 business hours to schedule your partnership discovery call.

A confirmation has been sent to your email address.

What Happens Next

Application review — Our partner team reviews your practice profile and license verification (24–48 hours)
Discovery call — 30-minute call to walk through the program, answer your questions, and confirm fit
Legal review period — We send the MSA and BAA templates for your Florida healthcare counsel to review (recommend 2–3 weeks)
Agreement execution — Both parties execute the MSA and BAA
Onboarding — White-label portal setup, staff training, and private-label packaging configuration (30 days)
Launch — Your branded program goes live

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