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Membership Application

The Santa Clara County Medical Association (SCCMA) and the Monterey County Medical Society (MCMS) are professional associations representing physicians and their patients in all modes of practice and specialties, including medical students and residents. Our strength and influence grows with our increasing membership, so please help do your part for organized medicine today.

Membership Application: Section 1 - Application Type
Are you currently a member of the California Medical Association or have you been in the past?Required  Yes      No
Are you currently a member of any other California county medical association or society?Required  Yes      No
Which County are you applying for?Required  Monterey      Santa Clara
Do you live or work in the County?Required  Yes      No
Are you on active
military duty?Required  Yes      No
Are you a full-time
medical student at
Stanford University?Required  Yes      No
If yes, what is your expected year of graduation? 
Are you a resident,
intern or fellow?Required  Yes      No

Program Name and Tenative Completion Date:
What membership category are you applying for?Required  Active      Student      Resident      Other

 

Membership Application: Section 2 - Personal Information
Physician First Name:Required
Physician Middle Initial:Optional
Physician Last Name:Required
Degree:RequiredNot required for Residents or Students
Additional Degrees/Accreditations:Optional
Physician Gender: Required  Male      Female
Date of Birth:Required
Birthplace:Optional
Medical School:Required
Graduation Year:Required
CA License #:Required
Date Issued:Required
Primary Mailing AddressRequired  Home      Office
Primary Office
Street Address:Required
Primary Office City:Required
Primary Office State:Required
Primary Office Zip Code:Required
Primary Office Phone:Required
Primary Office Fax:Optional
Home Street Address:Required
Home City:Required
Home State:Required
Home Zip Code:Required
Home Phone:Required
Home Fax:Optional
Email Address:Optional Publish Email?   Yes      No

 

Membership Application: Section 3 - Practice Information
Practice/Group Name:Optional
Website:Optional
Primary Specialty:Required
Board Certified?   Yes      No
Accepting Referrals?   Yes      No
Secondary Specialty:Optional
Board Certified?   Yes      No
Accepting Referrals?   Yes      No
Tertiary Specialty:Optional
Board Certified?   Yes      No
Accepting Referrals?   Yes      No
Referral Restrictions:Optional
 New Patients  MediCal Patients
 Medicare  Medicare Assignment
 Champus Patients  Convalescent Home
 Medical-Legal Referrals  FAA Cert. Physical
 Class 1 Driver's Exam  Insurance Exams
 Workers' Comp Exams  House Calls
 Eve Appointments  Saturday Appointments
 Sunday Appointments  Alcohol
 Second Opinions

 

Membership Application: Section 4 - Dues Payment Information

Please review dues below, as well as optional donations. PLEASE NOTE: Total FULL dues are listed below, however, new members to CMA are eligible for prorated dues depending on the date of election. The proration of your dues will be assessed and shown on the following payment screen (after you submit the application).

Required Dues

ACTIVE MEMBERS
Fee Type Recurrance Amount
 Application Fee One Time $125.00 
 California Medical Association Dues Annual $590.00 
 SCCMA/MCMS Dues Annual $350.00 
 
STUDENTS: SCCMA ONLY
Fee Type Recurrance Amount
 Application Fee One Time No Charge 
 American Medical Association Dues One Time $68.00 
 California Medical Association Dues One Time $20.00 
 SCCMA Dues One Time $12.00 
 
RESIDENTS
Fee Type Recurrance Amount
 Application Fee One Time No Charge 
 California Medical Association Dues Annual No Charge 
 SCCMA/MCMS Dues Annual No Charge 
 

Optional Donations for Active Members

MONTEREY COUNTY MEMBERS ONLY
Fee Type Amount
 Medical Doctors Political Action Committee (MD-PAC) $50.00 / $75.00 / $100.00 
 Resident Physician Fund $50.00 
 
SANTA CLARA COUNTY ONLY
Fee Type Amount
 Santa Clara County Physicians Political Action
   Committee (SAC-PAC)		 $50.00 / $75.00 / $100.00 
 Santa Clara County Residency / Student Fund $50.00 / $75.00 
 Santa Clara County Medical Association Alliance $105.00 
 
CALIFORNIA MEDICAL ASSOCIATION
Fee Type Amount
 California Political Action Committee (CAL-PAC) $100.00 
 California Political Action Committee -
   Physician's Issues Committee (CAL-PAC)		 $195.00 

 

Membership Application: Section 5 - Terms & Conditions of Use

The undersigned agrees in case of election that membership in the Santa Clara County Medical Association or Monterey County Medical Society shall be conditional upon compliance with the Constitution & Bylaws, and Principles of Medical Ethics of the CMA and the SCCMA/MCMS. The undersigned further agrees that he/she will recognize the authorized Officers of said Associations as the proper and sole authorities to interpret any doubtful point in professional conduct and will at all times abide by and be governed by their interpretations. The applicant also agrees to the website privacy policy and return policy. I hereby affirm that the information provided on this Application for Membership, and any addenda thereto is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that material omissions or misrepresentations may result in denial of my application and/or termination of my membership should I be elected a member of said Associations. I understand and agree that acceptance of this application, application fees, and/or dues, does not constitute approval or acceptance of my membership.

 I ACCEPT the Terms and Conditions of use.
 I DO NOT accept the Terms and Conditions of use (if selected your application will not be submitted and will be deleted).
The Bulletin

 

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Mar

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WEBINAR: HIPAA Update 2012

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Apr

27

15th Annual California Health Care Leadership Academy

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Apr

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CleanMed 2012 Conference

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