New Member Application

 
 

Name

 
 
 
 
 

Office Address

 
 
 
 
   
 
 
     

Home Address

 
 
 
 
 
 
 
 

Communications

 
 

Identifying Information

   
 
 
 
 

Marital Information

 
 

Practice Information

 
 
 
 
 

Medical School

 
 
   

Residency/Fellowship

 
 
   

Membership Qualification and Authorization

I hereby apply for membership in the County Medical Society and Texas Medical Association and, if accepted, agree to abide by and be subject to the terms and conditions of the Constitution and Bylaws of the Society and of the Texas Medical Association 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 Censors, I have a right to appeal the denial to the County Medical Society pursuant to the Hearings Procedure Manual. I understand that if my application for membership is denied, based on professional competence or conduct, the County Medical Society 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 hereby release, and hold harmless from liability or loss, the County Medical Society, the Texas Medical Association, and any other County Medical Society to which I transfer, their officers, agents, employees, and members for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the above named organizations, or their authorized representatives, concerning my professional competence, ethical conduct, character and other qualifications for membership.

I further authorize disclosure of information generally considered to be reliable which has a bearing on my professional competence, character, and ethical qualifications to all hospitals, medical discipline boards, and medical licensure boards which request such information.

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.

Note: Membership becomes effective when application has been approved by your county medical society board of censors and dues have been paid to the Association.