Membership Application - ACTIVE

Active membership is available to individuals having management responsibilities within an oncology hematology practice. (An administrator, office manager, or physician is normally the Active member).

Annual Dues:

Applicant Information

First Name
Last Name
Title/Position
Degree
Email Address
Date of Birth
Gender

Practice Information

Practice Name
Address
City State Zip
Phone
Fax
Total Practice Employees Total # of RN's
How Long Practice in Existence Total # of Physician Extenders
Physicians (Please List)
 

Additional Sites

Additional Sites (If yes, please list addresses below)
Satellite #1
Satellite #2
Satellite #3
Satellite #4

Additional Info

Practice Management System
AR Tool:
Other
Pyxis
EMR (Specify)
Internet Type
Practice Website
URL
Research
Ancillary Services
PET/CT
Complimentary Therapies
Retail Pharmacy
If other, specify
Practice Type
Community-based
Hospital-Owned
Hospital-Based
Multi-Specialty
If other, specify
ACKNOWLEDGEMENT

As a member of the Premier Oncology Hematology Society I agree that my practice will be represented at not less than two meetings or events in a year (the annual conference counts as one meeting). I further understand that failure to comply with these membership requirements may result in the revocation of my practice membership. I also understand under these conditions, membership dues are non-refundable

 
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