Physician Membership Application

To apply for physician membership, please complete all questions

Application Information

Name(Required)
Address(Required)
The MHA Physician Membership includes a paid membership to AAPL. If you are already an AAPL member, the MHA will pay your AAPL membership fee upon your next renewal.

Affiliated Organization Information

To become a Physician Member of the MHA, you must be affiliated with an MHA Member Organization.
Address(Required)

Assistant Information

Name
Note: Forms will not be accepted if they include URLs.
This field is for validation purposes and should be left unchanged.