Membership

Welcome , please complete the form below to extend or renew your membership.

If you are already subscribed, your current end date will be extended by one year. If your subscription is not current it will be activated for one year starting today.

If you'd like to automatically renew your subscription each year, select the Recurring Subscription option below.

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username*

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Start Membership Date

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End Membership Date

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EOT Lookup

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Role

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Account Holder's Name

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Paperless Billing

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Internal Status

General Information

Name

First Middle Initial (optional) Last Suffix (Optional)

Degrees and Certifications*

Use proper "Case" and insert commas between each to separate. This must be entered exactly as you would like it shown on a CME Certificate. Enter NA if not applicable.

Email

Your Email Address can be updated from the My Account link in the menu then in the profile section.

Phone

Specialty

SelectAllergy/ImmunologyAnesthesiologyCardiologyDermatologyEndocrinology/Diabetes/MetabolismEmergency MedicineFamily Practice/General PracticeFamily MedicineGeriatricsInternal MedicineMedical GeneticsNeurological SurgeryNeurologyObstetrics/GynecologyOncologyOphthalmologyOrthopedicsOtolaryngologyPathologyPediatricsPhysical Medicine & RehabPlastic SurgeryPreventive MedicinePsychiatryRadiologySurgeryUrologyOther

Date of Birth

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Base Rate

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Contact

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Education Information

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Current Education Status*

MS1MS2MS3MS4PGY1PGY2PGY3PGY4FellowPracticing

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Medical School*

School you attended or are currently attending

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Graduation Date*

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The date you graduated or plan to graduate

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Name of Residency Program*

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Residency Director's Name

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End of Residency Date*

MM slash DD slash YYYY

The date ended Residency or plan to end Residency

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Premium Upgrades

Airmed Upgrade

NoneSpouse ($150)Family ($195)

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Please provide the following information below for your Spouse and/or Family Member(s) to be added to Airmed.

Airmed Name*

First Last

Airmed Email*

Airmed Home Address*

Street Address City State / Province / Region ZIP / Postal Code

Airmed Phone*

Airmed Birth Date*

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Airmed Gender*

Male

Female

Additional Family Members on Airmed Plan*

Please provide full name, date of birth & gender of each dependent enrolling on plan. Dependent Children only up to age 26 years & must reside under the same household as SMA Member.

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Payment Type*

One Time Payment

Recurring Subscription

Total

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Check Received*

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Check Number*

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