Affiliate Application Form

Affiliate Membership Application


Email Address: *
First Name: *
Last Name: *
Title:
Practice/Organization Name: *
Affiliated
(If affiliated with another organization through ownership or legal affiliation,
please indicate the name of the organization.)
:
Business Address: *
Business Address 2:
City: *
State: *
Zip: *
Phone: *
Fax:
How did you hear about NFMGMA:
Referring member or organization:

Total number of practicing physicians in your facility

Physicians:
Physicians Assistants:
Nurse Practitioners:
Nurse-Midwives:
Physical Therapists:
Audiologists:
Other:

Please indicate ancillary services provided by your facility:

Lab:
Ultrasound:
Nuclear Testing:
X-Ray:
Ambulatory Surgery:
Physical Rehabilitation:
Nutrition/Wellness:
Home Health Care:

Please list any topics you would like to have a guest speaker present:
Are there any MGMA benefits you'd like to learn more about?:
Provide name/contact information for anyone who would benefit from becoming a member:
For potential Affiliate Members, please describe in detail the services your company can provide and what percentage of your business is devoted to medical practices:
Affiliate's Industry:
Accounting
Attorney-Healthcare
Attorney-Employment
Banking
Billing
Call Center
Collections
Communications
Employee Benefits
Financial Investing
Healthcare Management/Consulting
Human Recourses
Information Technology
Malpractice Insurance
Marketing
Medical Supplies/DME
Real Estate (Sales/Lease/Purchase)
Staffing/Recruiting
Training/Education