AMERICAN ASSOCIATION OF OSTEOPATHIC PHYSICIANS

MEMBERSHIP APPLICATION

(Membership runs annually January through December)

 

_____ Regular Membership $300 (DO, MD, Clinical PhD, etc.)

 

_____ Associate Membership $200 (PA, RN, Public Health, Non-Clinical PhD, etc.)

 

_____ Corporate Membership $500 (Pharmacies, Labs, Home Medical, etc.)

 

_____ Students, Interns, Residents (no dues)

 

_____ Retirees-(no dues are required but donations are welcome and appreciated)

 

State License No. ______________________ Specialty ______________________________________

 

Degree to appear with name: DO___ MD___ PhD___

 

Other_________________________

 

First Name ___________________________________________________________________________

 

Middle Initial _________________________________________________________________________

 

Last Name ___________________________________________________________________________

 

Please check preferred mailing address. Office address will be published in the Association’s Directory.

 

(___) Office ___________________________________________________________________________

                    Street                                                 City                                        State             Zip

 

(___) Home ___________________________________________________________________________

                   Street                                                 City                                        State             Zip

 

Office Phone _________________ Home Phone __________________ Cell Phone __________________

 

Email _______________________________ Fax __________________________________

 

THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS A RIGHT TO REFUSE TO PAY, CANCEL PAYMENT, OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION, OR TREATMENT THAT IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED FEE, OR REDUCED FEE SERVICE, EXAMINATION, OR TREATMENT.

 

I am applying for membership in the American Association of Osteopathic Physicians, and I agree to comply with its bylaws and code of ethics.

 

Signature __________________________________________ Date ____________________________

 

Mail your application with check to:

American Association of Osteopathic Physicians

7853 Gunn Hwy, #222

Tampa, FL 33626

For questions email us at amaop4vets@gmail.com or call us at 813-475-6242.

 

Thank you for your interest in the American Association of Osteopathic Physicians!