AMGA Medical Group Application for Membership

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 .

Name of organization *

Phone *

Fax *

Website *

Address *

City *

State *

Zip Code *

Top Executive:

Name

Title

Top Physician Leader:

Name

Title

Top Operations Leader:

Name

Title

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 *

Submitter Email *

Submitter Phone *

AMGA Annual Dues Structure

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

Organizations that Contract
with Physicians (IPA)

# of FTE Physicians Dues # of Enrollees Dues

3 - 50 $ 6,250 Up to 60,000 $ 6,250

51 - 150 $11,250 60,001 - 180,000 $11,250

151 - 500 $16,750 180,001 - 600,000 $16,700

501 - 1,000 $19,500 600,001 - 1,200,000 $19,500

1,001 - 1,500 $26,000 More than 1,200,000 $26,000

1,501 - 2,000 $32,000

2,001 - 2,500 $38,000

2,501 - 3,000 $44,000

3,001 - 3,500 $50,000

3,501 - 4,000 $56,000

4,001 - 4,500 $62,000

For organizations with more than 4,500 physicians, dues will increase in the same proportioned manner.

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 .

Fields marked with * are required.

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