Membership Application CMGMA

General Members: Please complete the following
Please indicate practice specialty/specialties:
  

[  ] Allergy, Immunology, Asthma [  ] Oral/Maxillofacial Surgery
[  ] Ambulatory [  ] Orthopedic Surgery
[  ] Anesthesiology [  ] Otolaryngology
[  ] Cardiology, Thoracic Surgery, Cardiovascular [  ] Pathology
[  ] Dermatology [  ] Pediatrics
[  ] Endocrinology [  ] Physical Therapy
[  ] Family Practice [  ] Plastic/Reconstructive Surgery
[  ] Gastroenterology [  ] Podiatry
[  ] Hematology/Medical Oncology [  ] Psychiatry
[  ] Internal Medicine [  ] Pulmonary
[  ] Multi-Specialty [  ] Radiology
[  ] Neurology [  ] Surgical/Ambulatory Surgery
[  ] Neurosurgery [  ] Urgent Care/Industrial Medicine
[  ] Obstetrics/Gynecology [  ] Urology
[  ] Occupational Medicine [  ] Other (please specify)_______________________
[  ] Ophthalmology

      

____ # practitioners

____

 # non-physician clinical staff
____ # administrative staff

____

 # total staff
Are you a member of the National Medical Group Management Association (MGMA)?

_____ yes

_____ no
If no, would you like information about membership with MGMA?
_____ yes _____ no
Are you a member of the American College of Medical Practice Executives?
_____ yes _____ no
If yes, what is your present status? (Nominee, Certified, Fellow)
____________________________________________________
If no, would you like information on the College?
_____ yes _____ no

  

Allied and Affiliate Members: Please complete the following
What type of organization do you work for (i.e., accountant, lawyer): ________________________________________

  
_________________________________________________________________________________

  

What is the size of your organization? ______ # of staff members

Membership Application
[    ] General Membership [    ] Allied Membership [    ] Affiliate Membership

  

Name ____________________________________
  

Title ____________________________________________

Organization  ______________________________
 

Address _________________________________________
City _____________________________________
  		State _________ Zip Code ___________
Phone ___________________
    		Fax ___________________ E-mail __________________
Home Address_____________________________
   		City _______________ State______ Zip Code ___________
Home Phone ______________________________

Where do you want your mail sent?

 [   ] home [   ] office
  

Company Membership Application
Primary company representative, please fill out above
Second Company Representative Third Company Representative
      
Name _____________________________________
  		     
Name _____________________________________
Title ______________________________________
  		Title______________________________________
Company __________________________________
  		Company __________________________________
Address ___________________________________
     		Address ___________________________________
Phone _______________________
   		Phone _______________________
Fax _________________________
   		Fax _________________________
E-mail _______________________
    		E-mail _______________________
Total Number of Company Members__________
    		Total Amount Enclosed $____________
If additional members, please attach a separate sheet with above information.
Please charge to MasterCard/Visa/American Express
Card Number ____________________________________
    
Exp. Date: _______________________________________
    
Name as it appears on card ____________________________________________________
       
Signature _________________________________________________________________
  Print

Or make check payable to CMGMA
Mail to: CMGMA, One Regency Drive, P.O. Box 30, Bloomfield, CT 06002