Become a MemorialCare Physician Society Member

Please complete the enrollment and agreement form below.
*All fields are required.

Full Name:

First Name	MI	Last Name

Hospital Specialty:

Specialty

Medical Center/Hospital Affiliation:

Practice Name:

Medical Staff Status:

Office Address:


Street Address	City	Zip Code

Phone, Fax & Time to Reach:


Phone # with area code	Fax # (type none if no fax #)

Email Address:

Shirt Size:

Membership Agreement:

MemorialCare extends its membership benefits and opportunities to physicians throughout our health system. Completion of this enrollment form and agreement to the following are required:

1) I am a medical staff member in good standing at a MemorialCare Medical Center or affiliated medical group.

2) I am committed to utilizing MemorialCare Best Practice guidelines when appropriate to my patient’s circumstances.

3) I support and participate in physician performance reporting.

4) I will become proficient in the MemorialCare clinical information system.

5) I am committed to integrating evidence-based medicine into my practice.

6) I will maintain an active email address for my Society communications.

7) I understand that my membership in the MemorialCare Physician Society is contingent upon my fulfillment of these requirements and the approval of the Physician Society Board.

I agree to the TERMS AND CONDITIONS. I certify that the information provided above is true and correct. I agree that MemorialCare, its representatives, and any individuals or entities providing information to MemorialCare in good faith shall not be liable to, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document. I hereby give permission to release to this MemorialCare information about my medical practice insurance coverage and malpractice claims history. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the content of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in this form to discuss any information regarding this case with MemorialCare.

Note: Membership in MemorialCare Physician Society is at the sole discretion of MemorialCare.

For additional information about the MemorialCare Physician Society or for questions about this form, please call 866-405-EPIC (3742).