AMGA Medical Group Application for Membership

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Your form submission WILL be encrypted using SSL to ensure your privacy.

How to Join: To join, simply complete this application. For additional information on the benefits of membership please contact Bill Baron at (703) 842-0775, or wbaron@amga.org .

AMGA Medical Group Application for Membership
Name of organization *
Phone *
Fax *
Website *
Address *
City *
State *
Zip Code *
Top Executive:
Name
Title
Email
Top Physician Leader:
Name
Title
Email
Top Operations Leader:
Name
Title
Email

Best person to update organizational information and roster:

Name
Title
E-mail
Organizational Context (i.e., group practice, IPA, IDS, Academic Practice) *
Tax Status (select one) *
Number of Physicians *
Number of Prepaid Enrollees
Number of Employees
Number of Satellite Facilities
Number of Active Patients
Electronic Health Record System
Fiscal Year
Date *
Submitter Name *
AMGA Annual Dues Structure

Organizations that Employ Physicans
(Group Practice, IDS, Academic/Faculty Practice)

# of FTE Physicians

Dues

3 - 50

$5,950

51 - 150

$10,750

151 - 500

$15,950

501 - 1,000

$19,000

More than 1,000

$25,000

Organizations that Contract
with Physicians (IPA)

# of Enrollees

Dues

Up to 60,000

$5,950

60,001 - 180,000

$10,750

180,001 - 600,000

$15,950

600,001 - 1,200,000

$19,000

More than 1,200,000

$25,000




Fields marked with * are required.

Your form submission WILL be encrypted using SSL to ensure your privacy.

AMGA | One Prince Street, Alexandria, VA 22314-3318
(703) 838-0033 phone (703) 548-1890 fax
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