Medical Group Organization Membership Application

This application is to be used for medical groups interested in an organizational membership. By applying for an organizational membership medical groups are allowed to have an unlimited number of leaders from their organization as a member of the association. The following are the levels and cost for these levels of organization memberships:

Large Medical Groups - any medical group with greater than 300 employed physicians             Cost: $2,000 annually

Medium Medical Groups - any medical group between 150 and 299 employed physicians         Cost: $1,500 annually

Small Medical Groups - any medical group with less than 150 employed physicians                     Cost $1,000 annually

What type of medical group membership are represents your medical group?: *
Name of Medical Group: *
Address Line 1: *
Address Line 2:
City: *
State: *
Zip Code: *
Contact Name (Name of person who will manage the members of the group & process invoice payments):: *
Contact Address (if different from organization address):
Contact Address Line 2:
Contact City:
Contact State:
Contact Phone Number: *
Contact Email Address: *
# of Physicians in the Medical Group: *