ARIZONA PODIATRIC MEDICAL ASSOCIATION

Transcription

1 ARIZONA PODIATRIC MEDICAL ASSOCIATION APPLICATION FOR MEMBERSHIP All materials should be typed and answered in full. Failure to do so will delay the membership process and/or result in your application being returned for completion. Your completion and submission of the application does not guarantee an automatic election to membership in this voluntary organization. Applicants are encouraged to be present at the meeting during which membership is voted. Please read the following and submit the required information. Failure to submit all information and fees will delay processing. A completed original application for membership in the American Podiatric Medical Association A copy of your Arizona license to practice podiatric medicine A copy of your DEA registration or narcotic license Board Certification certificate(s) Board Qualified documentation A sample of your current stationery and business card Your address for future correspondence A check payable to the AzPMA for $ covering the application fee A second check payable to AzPMA for APMA and AzPMA dues representing six months of dues. Please call Dr. Ralph B. Rabin, Treasurer of the AzPMA, at (623) so he may determine the amount of your dues payment. Please send the application to Dr. Niemann certified return receipt. These applications must be completed and returned within 90 days (expires on 8/24/2010). Please mail the completed application with all required information to: Dr. Spencer Neimann, Secretary AzPMA 444 W Osborn Road, #301 Phoenix, AZ Phone: (602) Fax: (602)

2 ARIZONA PODIATRIC MEDICAL ASSOCIATION APPLICATION FOR MEMBERSHIP Name: Birth: Last First Middle Spouse: Date Place Name Sex CHECK THE ADDRESS FOR AzPMA MAILING USE: HOME: OFFICE: MAILING (If Different): AREA CODE & TELEPHONE. AREA CODE & TELEPHONE. AREA CODE & FAX. EDUCATION AND TRAINING Podiatric Medical Education: SCHOOL DEGREE DATE Residencies: Arizona License: DATE ISSUED NUMBER Others: STATE DATE ISSUED Board Certification: Board Qualified: MEDICAL PRACTICE Type of Practice: (Check appropriately) Office Based Solo Group (Associated With:) Hospital Government Other (Explain:) Last 10 year s Practice: Location: APMA Membership: Active Hospital Affiliations: Specialty Society Memberships: Specialty Podiatric Interests: I hereby apply for membership in the Arizona Medical Association and will submit annual dues, fees, and assessments when due and payable if elected to membership. I understand that no one has an automatic right to be elected to membership in the voluntary organization.

3 I. Licensure Have any disciplinary actions been initiated or are any pending against you by any state licensure board? Has your license to practice in any state ever been denied, limited, suspended, or revoked? Have you ever been suspended, sanctioned, or otherwise restricted from participating in any private, federal, or state health insurance programs? Have you ever been the subject of an investigation by any private, federal, or state health insurance program? Has your narcotics registration certificate ever been limited, suspended, or revoked? Is your narcotics registration certificate currently being challenged? Have you ever been convicted of a felony? Has your license to practice podiatric medicine in any jurisdiction ever been limited, suspended, or revoked (other than for non-payment of fees)? Have your privileges in any hospital ever been suspended, diminished, revoked, or not returned? Have you ever had any of the following items denied, revoked, suspended, not renewed, placed under probation, subjected to disciplinary action, or otherwise limited or curtailed: or have you voluntary relinquished any item in anticipation of any of the following item? (If yes, mark the appropriate box and explain details on a separate sheet of paper.) State License DEA registration or other narcotic license Hospital or other health care facility staff membership or privileges Professional organization membership Medicare, Medicaid, AHCCCS, or other government program participation HMO, PPO, or other prepaid health plan participation II. Insurance Has your professional liability insurance ever been denied, suspended, cancelled, or not renewed? Has your present professional liability insurance carrier excluded any specific procedures from your coverage since your last reappointment to a hospital? III. Legal Action Are you now or have you ever been named as a defendant / codefendant in any malpractice suit, including arbitration? Has any malpractice claim settlement ever been paid by you or paid on your behalf? Have any professional liability been filed against you which are presently pending? N / A If you have ever been employed as a podiatrist by a military service, a hospital, an HMO, or any other health care organization, was your employment ever terminated by the employer?

4 IV. Release of Professional Liability I authorize the release and exchange of information between my Professional Liability Insurance Carrier and the Arizona Podiatric Medical Association: NAME OF CARRIER: PHONE: ADDRESS: Amount of coverage: Policy.: I request that my Carrier send to the Arizona Podiatric Medical Association a Certificate of Insurance or other document that includes the following information: Coverage for which insurance is afforded Limits of liability Policy Number Issue date and expiration date Type of insurance (claims made / occurrence) Claims history I also request my Carrier to furnish the following: All claims experience resulting from suite and third party claims (I understand that this information is public information.) I authorize my Carrier to notify the Arizona Podiatric Medical Association of any future changes, reductions in coverage, termination of coverage, or failure to renew coverage within 30 days of cancellation of coverage. I release from liability all representatives of Insurance Company for their acts performed in good faith and without malice in supplying information for the completion of my application for membership processed by the Arizona Podiatric Medical Association. V. Malpractice Report Form Please answer each of the following questions in full. If any malpractice suit has been filed against you or you have been named in any suits, please Copies of this page may be made as needed. PLAINTIFF NAME: AGE: ADDRESS: INSURANCE CARRIER: POLICY.: PLEASE CHECK THE BOX UNDER EACH HEADING: NATURE OF CLAIM: Wrongful Death Delayed Diagnosis Missed Diagnosis Jury Award* Lack of Informed Consent Foreign Body Complications of Therapy Unnecessary Surgery Incorrect Procedure Other: DISPOSITION: AMOUNT: DATE: Pending Settlement* Dismissed* (For all (* Please forward legal court documents regarding the outcome of this claim.)

5 IV. Release of Professional Liability I hereby authorize to furnish the Arizona Podiatric Medical Association with information regarding claims experience resulting from suits and third party claims. I release from liability all representatives of the above named carrier for their acts performed in the good faith and without malice in supplying information for the completion of my application for a membership appointment processed by the Arizona Podiatric Medical Association. I hereby release from liability the Arizona Podiatric Medical Association (the Association ) and all its employees and agents for those acts performed in good faith and without malice in connection with the obtaining, verifying, and evaluating my application as needed. In addition, I hereby release from any liability any and all individuals and organizations (including hospitals and / or military agencies) and their agents and employees, who have provided information to the Association in good faith and without malice. I authorize and consent to the Association s representatives, as well as representatives from hospitals and agencies, I have designated to consult with prior associates or hospital affiliates who may have information bearing on my professional or ethical qualifications and competence and consent to the inspection of all records and documents that may be material to the evaluation of my qualification and competence. If requested, I hereby agree to a personal interview to discuss any information submitted by me or any other source to the Association. I hereby acknowledge my obligation to immediately advise the Association in writing of any new, different, or additional information responsive to any question if the information requested in this application, which, at any time, comes to my attention or is made known to me. I understand that these applications must be fully completed by me and returned within 90 days. All inquiries from the Secretary must be completed via return mail. By signing and submitting this application, I hereby attest to the correctness and completeness of all information provided by me. Submission of false information on this application may result in expulsion from the Association. NAME OF APPLICANT: SIGNATURE OF APPLICANT: DATE: