Indiana State Medical Association Member Application

Instructions: This is an electronic version of the ISMA member application. Please type your information into the fields provided. When you’ve completed the online member application process, this application will be automatically emailed back to the ISMA for processing. If you wish to fill out the application by hand, you may print it and mail the completed form back to the address listed at the end of the application. Vigo County and Fort Wayne physicians must print and fill out additional addendums for those counties. The addendum must be mailed in and will be included in your confirmation email.

If your application will be completed entirely online, then dues payment (AMEX, MasterCard or VISA credit card) is required to complete the transaction.

*Denotes Required Field
County  
Category  
 
Resource code:
Personal Information
*First name   Middle name *Last name   Title
Maiden name:
Place of Birth – City, State *Date of Birth  
(MM/DD/YYYY)		 *Gender  
Spouse's name please include title, such as MD or DO, if applicable
HOME address:
*Street (line 1)  
Street (line 2)
*City   *State   *Zip    
*Home phone(no dashes)     Home FAX(no dashes)  
Personal email (your email will not be given to third parties)
 
PROFESSIONAL INFORMATION
SpecialtyBoard certified (year)
*Primary  
Secondary  
ADDRESSES and PHONE NUMBERS
*PREFERRED ADDRESS:
*List your PRIMARY OFFICE address:
*Street (line 1)  
Street (line 2)
*City   *State   *Zip    
*Office phone#(no dashes)     Office FAX#(no dashes)  
*Email for all ISMA communications
(your e-mail will not be given to third parties) 		Pager number (no dashes)
     
Corporation/practice name:
Office manager:
Previous practice location:
Military service - branch Date begun (MM/DD/YYYY)
Military reserves Date completed (MM/DD/YYYY)
*Medical school  
*Year of graduation (YYYY):    
ECFMG (if applicable) ECFMG issue date (MM/DD/YYYY)
Residency 1:
Date started
(MM/DD/YYYY): 		Date completed/Expected
(MM/DD/YYYY):
Residency 2:
Date started
(MM/DD/YYYY): 		Date completed/Expected
(MM/DD/YYYY):
Fellowship 1:
Date started
(MM/DD/YYYY): 		Date completed/Expected
(MM/DD/YYYY):
Year of IN license *Indiana license number   NPI number
(National provider identification)
CSR # Federal DEA #  
 
Are you currently accepting:
Medicare patients? Medicaid patients? Medicare assignments?
Foreign languages: (Use buttons to select)
Available   Selected

Type of Practice:
Network:
Who recruited you to the county/ISMA medical societies?
Previous medical society memberships:
National and state specialty society memberships:
Hospital affiliations: (Use buttons to select)
Available   Selected

If submitting your application by mail, please mail to: Attn: Vicki Riley, 322 Canal Walk, Indianapolis, IN, 46202-3252
Questions: (317) 454-7735 or 1-800-257-4762, Fax: (317) 261-2226
PLEASE NOTE
The following information may be disseminated for public use:
Office address and phone numbers
Specialties and board certifications
NP8 numbers
Medical school of graduation and graduation date
Any additional information supplied will be used for statistical purposes ONLY.

Renewal of your county, state and district memberships will be due by January 15th of each calendar year. An optional contribution to the Indiana Medical History Museum may also be included.

If dues payment is not included with this application, the Indiana State Medical Association (ISMA) will forward a dues invoice. Medical Association dues (except for specific governmental affairs expenses) may be deductible as professional or business expense to the extent allowable by law. Dues and other contributions to the ISMA and any county or district society are not deductible as charitable contributions for federal income tax purposes.