An Invitation to Join the Capital Medical Society

Personal Information

Full Legal Name:

Nickname:

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 internal organizational use.

Where do you prefer to receive emails?

HomeOffice

Home Address

Home Phone:

Cell Phone:

Address:

City/State/Zipcode:

Personal Email Address:

Office Address

Phone:

Address:

City/State/Zipcode

Office Email Address:

Fax Number:

Education

Medical School:

Degree (Date):

Internship (Institution & Date):

Residency (Institution & Date):

Fellowship (Institution & Date):

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

Board Of Certifications

Name of Board:

Certified on:

Name of Board:

Certified on:

Hospital Affiliations

Primary:

Secondary:

Media Consent

I hereby authorize the Capital Medical Society (CMS) to use my photographs, audio recordings, and/or video recordings taken of me during events for educational and/or promotional purposes. I understand this information becomes the property of CMS and may also be used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, social media platforms, and/or other similar ways determined by CMS. I understand this Consent remains in effect as long as I remain a member of the Capital Medical Society.

YesNo

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.

We Care Network

Currently 300 of your fellow physicians in Tallahassee volunteer in this program, donating specialty care to low-income, uninsured patients in great need. In addition, 40 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.

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:

Today's date:

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