Physician Membership Application Associate Members Awards Advancing Safe Care Award Advancing Safe Care Award Nomination Form Healthcare Leadership Award Healthcare Leadership Nomination Form Ludwig Community Benefit Award Ludwig Community Benefit Nomination Form Meritorious Service Award Speak up Award Special Recognition Award Board of Trustees Careers at the MHA Current Opportunities Committees Councils Member Benefits Associate Membership Bylaws Data Reporting Services Membership Application Physician Membership Physician Membership Application MHA 100 Year Anniversary Celebration 100 Year Anniversary Timeline Our Hospitals Michigan Hospitals By Health System Staff Directory To apply for physician membership, please complete all fieldsApplication InformationName(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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Are you a current member of the American Association for Physician Leadership (AAPL)?(Required)Yes - Please pay for my AAPL MembershipNo - and I would like a complimentary AAPL membership paid for by MHANo – I do not wish to become an AAPL memberYour 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 MemberAffiliated Organization InformationTo 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)EmployedContractedAssociatedIndependentOwnership Type(Required)Non-ProfitFor-ProfitPhone(Required)Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Assistant InformationName First Last Title Email PhoneNote: Forms will not be accepted if they include URLs.CommentsThis field is for validation purposes and should be left unchanged.
