This is a <select a reason> New member application Information change Other

Applying for:         <select a membership category> Active Affiliate Student

Referred by:

E-mail address:    
(required)

Last name: 

First name: 

Title: 

Company name:  
 

Office address:     
  

City       
State     Zip 

Work phone:          
Work fax:        

Home phone:

Type of organization: 
<select organization type> Accounting Firm Billing Service Firm Consulting Firm Financial Services Freestanding ASC Freestanding Rehab Facility Freestanding Urgent Care Facility Health Maintenance Organization Hospital Integrated Health System Independent Practice Association Insurance Company Law Firm Management Services Organization Medical Practice Medical Supply Company Office Supply Company Pharmaceutical Company Physician Hospital Organization Physician Practice Management Company Provider Sponsored Organization Recruitement Services Firm Software Vendor University Other - describe in comments below

If a medical practice:

Number of FTE physicians:   
FTE mid-level providers:     

Type of practice:  <select practice type> Single specialty, primary care only Single specialty, specialty care only Multispecialty, primary and specialty care Multispecialty, specialty care only Other (describe in comments)

Specialties represented: 

Ownership of your practice:  
<indicate ownership> Physician-owned Hospital-owned University/Medical School owned Government owned PPMC/For-Profit owned Other (describe in comments)

Comments: