Membership Application Online

Dade County Medical Association
1501 NW North River Drive Miami, FL 33125
Tel: (305) 324-8717 Fax: (305) 325-1316
“Promoting Quality Medical Care since 1903.”

LET YOUR VOICE BE HEARD!
JOIN THE DADE COUNTY MEDICAL ASSOCIATION!

We take care of you…
So you can take care of your patients.
But, we need your help.
The DCMA is the largest medical association in Miami Dade County representing you and your patients. We cannot be effective unless all physicians join.
Membership…You Can Count on the Benefits!
Advocacy in the Florida Legislature
Intervention with Government Agencies
Discounts on All Insurance Needs
and much more. For more information go to www.miamimed.com
Name :
Office Address:
City: State: Zip:
Physician Referral Program: Yes No
Office Telephone:
Office Fax:
Date of Birth (required):
Email address:
Specialty:
   
Members abide by the AMA Principles of Medical Ethics and the bylaws of the Associations. To assist us in upholding these standards, please provide answers to the following questions, sign and date. If you answer yes to any of these questions, please attach full information.
Have you ever been convicted of fraud or a felony?
Yes No
Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions.
Yes No
Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff? Yes No
I am aware that the information submitted in this application will be verified. I hereby authorize other organizations having information relating to this application, including governmental and regulatory entities, to release any and all such information. Yes No