Membership Application

First Name:	*
Last Name:	*
Title:
Credentials:
Organization:	*
Referred/Sponsored By:
E-mail Address:	*
Cell Phone:

Work Address:	*

City:	*
State:	*
Zip Code:	*
Work Phone:	*
Extension:
Fax:
	* Required

Home Address:

City:
State:
Zip Code:
Home Phone:

Membership Type:	Active: works with one or more physicians engaged in the practice of medicine OR works for an organization whose staff provides management services through a specified agreement for one or more physicians engaged in the practice of medicine. The member's principal role must be on of the following: a) performing managerial duties involving multiple areas; or b) performing administrative tasks involving a single area; or c) providing patient care and also performing significant managerial or administrative tasks. An active member is entitled to all Association membership services, including the right to vote on all matters and to serve as an officer of the Association. Active membership fee: $100
	Allied: works for an association that provides services and/or products for physician offices. Allied membership fee: $150
	Student: full-time student of a Mississippi college/university who is planning a career in medical management. Student members may not vote and may not hold office. Student membership fee: $50
Are you a member of the National MGMA? Yes No

Practice type:

Single Specialty
Multi Specialty (primary & specialty care)
Multi Specialty (primary care only)
Multi Specialty (specialty care only)
Specialty:

Practice Ownership

Physician Owned
Hospital Owned
FQRHC/RHC

Providers
Number of full-time/FTE physicians:
Number of full-time nonphysician providers:

Select the networks you participate in:
Medicare	Medicaid	BCBS	Aetna	Cigna	UHC

What Practice Management Software do you use?

Are you using an EMR? no yes
If yes, which software?

Online Credit Card Payment:

Name on Card:
Type:
Card Number:
CVV:	what's this?
Expiration Date:	(mm/yyyy)

If you wish to pay by check, please print this form and mail it with your payment to:

MGMA of MS
P.O. Box 186
Sumrall, MS 39482

Do not click the submit button below if paying by check.