TMA Telemedicine New Member Application

Resource code

What is this?

Name

First name *

Middle name

Last name *

Suffix

Office Address

Office Address information provided will be visible in the Find a Physician search that is publicly available.

Address 1 *

Shown in Public Profile

Address 2

City *

State *

Zip *

Phone *

Shown in Public Profile

Fax

Physician Email *

Practice Administrator Name

Practice Administrator Email

Home Address

Address 1

Address 2

City

State

Zip

Phone

Communications

Preferred mailing

Office Address

Home Address

Preferred billing

Office Address

Home Address

Mobile Phone

Allow Texts from TMA

Identifying Information

Date of Birth *

Gender *

Texas Medical License #

Marital Information

Marital Status

Spouse's Name

If married, is spouse also a physician?

Yes

Practice Information

Practice type

Direct Patient Care

Teaching/Reasearch

Administration (non-clinical)

Not in Patient Care

Military

Veterans Affairs

Retired/Semi-retired/Temporarily not in Practice

Practice Location

Independent Care

Hospital Based/Hospital Employed

Locum Tenens

Medical School/Academic Setting

Practice Size

Solo

5 or under

6 or more

Primary specialty *

Secondary specialty

Is your practice under the umbrella of, or operating as a satellite location for a larger healthcare organization?

Yes, Physician Network

Yes, ACO

Yes, IPA

If yes, Name of Organization

Who is responsible for providing or acquiring services for your practice such as HR, CME, accounting and collections, technology (hardware/software), and compliance tools/resources?

Me or the physicians in my immediate practice

Umbrella organization/hospital

Allotment provided by employer

Medical School

Medical school *

Degree *

Graduation date *

Residency/Fellowship

Residency/Fellowship *

Specialty *

Completion date *

Membership Qualification and Authorization

I hereby apply for membership in the Texas Medical Association and, if accepted, agree to abide by and be subject to terms and conditions of the Constitution and Bylaws of the TMA and the Principles of Medical Ethics of the American Medical Association. In order to process my application for membership, I grant permission and consent for you to obtain from any appropriate source all relevant information concerning my credentials and qualifications.

I understand that if my application for membership is denied by the Board of Councilors, I have a right to appeal pursuant to the Hearings Procedures Manual. I also understand that if my application for membership is denied, based on professional competence or conduct, the Board of Councilors must report such a professional review action to the National Practitioner Data Bank through the Texas Medical Board within 15 days of the date that all due process rights have been exhausted.

I also agree that biographical information will be disseminated in accordance with the policy and procedures established by the TMA Board of Trustees unless otherwise directed by me.

Have you ever had an application for membership in a medical society rejected?

Yes

Have you ever been convicted of a crime other than a non-felony motor vehicle violation?

Yes

Has your medical license ever been revoked or suspended?

Yes

Have you ever been subjected to disciplinary action by the Board of Medical Examiners?

Yes

Have you ever been subjected to disciplinary action by a County/State Medical Society?

Yes

Have you ever been subjected to disciplinary action by Hospital Medical Staff?

Yes

Signature of physician applicant *

Preparer's name and title (if other than physician)

By checking this box I authorize my electronic signature *

Note: Membership applications are not approved immediately, but must be reviewed by the Texas Medical Association and the County Medical Society (when applicable). Eligibility for member pricing on CME and all member benefits may be subject to delays due to disciplinary status, criminal history, or other circumstances.