AMGA Medical Group Application for Membership

Please do not complete this form. Our membership application is currently being upgraded. To begin an organizational membership, email membership@amga.org. We'll open membership access and begin onboarding your organization as soon as we hear from you.

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 *
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                                   $  6,600                                                    Up to 60,000                              $  6,660

 51   -   150                                $12,000                                                    60,001 -   180,000                      $12,000

151 -    500                                $17,600                                                  180,001 -   600,000                      $17,600

501 -    1,000                             $21,000                                                  600,001 - 1,200,000                     $21,500

1,001 - 1,500                             $27,300                                                 More than 1,200,000                     $27,300

1,501 - 2,000                             $33,600

2,001 - 2,500                             $40,000

2,501 - 3,000                             $46,000

3,001 - 3,500                             $53,000

3,501 - 4,000                             $59,000

4,001 - 4,500                             $65,000

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

How did you hear about us?

How to Join: To join, simply complete this application. For additional information on the benefits of membership please contact Jessica Prior at (703) 838-0033 ext. 392, or jprior@amga.org .




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