Physician Membership Application

URL

This field is for validation purposes and should be left unchanged.

To apply for physician membership, please complete all fields

Physician Application Information

Name(Required)

First Last

Credentials(Required)

Title(Required)

Certifications

Specialties/Sub-Specialties

Areas of Professional Interest

Email Address(Required)

Phone(Required)

Address(Required)

Street Address City State Zip

Are you a current member of the American Association for Physician Leadership (AAPL)?(Required)

Your MHA Physician Membership includes a paid membership to AAPL. If you are already an AAPL member, the MHA will pay your AAPL membership dues upon your next renewal with AAPL.

Please share why you chose to become an MHA Physician Member

Affiliated Organization Information

To become a Physician Member of the MHA, you must be affiliated with an MHA Member Organization/Hospital.

Affiliated Organization Name(Required)

Affiliation with Organization(Required)

Ownership Type(Required)

Phone(Required)

Address(Required)

Street Address City State Zip

Assistant Information

Name

First Last

Title

Phone

Note: Forms will not be accepted if they include URLs.

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MHA Headquarters

2112 University Park Dr.
Okemos, MI 48864

Phone: (517) 323-3443
Fax: (517) 323-0946

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