To become a MemorialCare Physician Society Member please complete the enrollment and agreement form below. *All fields are required.

Practice Address
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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:

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

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

- I support and participate in physician performance reporting.

- I will become proficient in the MemorialCare clinical information system.

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

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

- 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.

Terms and Conditions

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 information about my medical practice insurance coverage and malpractice claims history to MemorialCare. 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).

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