An Invitation to Join the Capital Medical Society

If you are a current member, you can login here.

At Capital Medical Society, we offer our members access to continuing medical education programs, physician referral services, legislative advocacy, social activities, employment services, current medical information and resources via Cap Scan (a monthly newsletter) and other communication, pager rental and a variety of committees and review boards among many other services.

Membership is available to all qualified allopathic (M.D.) and osteopathic (D.O.) physicians in our four counties: Leon, Gadsden, Jefferson, and Wakulla. Please review the information below and complete the membership application below to submit your membership request to our review board.

Capital Medical Society Annual Dues

Full Active: $425.00

Active 1st year: $250.00

Associate: $285.00 (military, state or federal employee)

Retired: $150.00 with meals

Retired: $50.00 without meals

Resident: $25.00

Medical Student: $20.00 (four years)

The Capital Medical Society encourages you to consider joining the Florida Medical Association (FMA). We believe we are most effective as an advocacy organization for physicians when we act in partnership with our statewide organization. To find out more about becoming an FMA member, click here.

 

CMS Membership Application (or, to inquire about the Alliance for spouses email hmluu@hotmail.com)

Please fill out the information in the application form below to become a member. Once you have been approved by the CMS Board of Governors, we will email you a password to access the ‘Members Only’ information.

Personal Information

Full Name:

FL Medical License #:

NPI #:

Sex:
MaleFemale

Date Of Birth:

Place Of Birth:

Spouse's Full Name:

Practice/Group Name:

Practice/Group Administrator:

Practice/Group Administrator Email Address:

Practice Type:
SoloGroupEmployedGovernment BasedAcademicOther

Primary Specialty:

Secondary Specialty:

Name of CMS member that recruited you:

Do you have an active Facebook account?
YesNo

If so, how are you listed?

Mailing Information

Please provide both addresses for our personal use.

Where do you prefer your mail to be sent?
HomeOffice

Home Address

Phone:

Address:

City/State/Zipcode:

Office Address

Phone:

Address:

City/State/Zipcode

Email Address:

Fax Number:

Education

Medical School:

Degree (Date):

Internship (Date):

Residency (Date):

If you have completed your residency, please upload your CV:

Residency (Date):

Board Of Certifications

Name of Board:

Certified on:

Name of Board:

Certified on:

Hospital Affiliations

Primary:

Secondary:

Membership Application & Qualification Questions

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 a felony or fraud?
YesNo

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.
YesNo

Have you ever been the subject of any disciplinary action by any medical society or hospital medical staff?
YesNo

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.

I understand that any false or misleading statement made on my application may be grounds for denial of membership or probation or censure by, or suspension or expulsion from the medical society(ies).

The foregoing information is true and complete.

Currently 315+ of your fellow physicians in Tallahassee volunteer in this program, donating specialty care to low-income, uninsured patients in great need. In addition, 49 dentists volunteer to provide dental care.

Medical social workers, employed by the Capital Medical Society Foundation, carefully screen patients for eligibility. These medical social workers provide case management and refer patients on a fair rotation basis to the different specialists. Once you finish providing treatment to a We Care patient, the patient is referred back to their primary care home. They do not become your permanent responsibility. Patients are very grateful for the medical care you provide, and you will find this a rewarding experience.

When you join the We Care Network, you are joining an impressive, award-winning program. All the medical providers in town participate: from both hospitals, to labs, imaging centers, durable medical equipment to home health.

And, as a physician volunteer with the We Care Network, you are eligible for up to 5 CME credits per biennium.

Yes, I will participate in the We Care Network.

I will agree to see ___ patients per month or ___ per year.

Yes, I want a Sovereign Immunity Contract that will protect me as a We Care Volunteer.

Who do we contact in your office to schedule We Care Patients?

What is their phone number?

No, I cannot participate at this time; please contact me again.

Full Name:

Signature:

Today's date: