“Serving and supporting physicians in their efforts to improve the health of Oregonians”

Contact | Join | Login

Search this site:

Email this page
Facebook
Twitter
RSS

Home
About
Media
Membership
Education & Events
Advocacy
Practice Help Center
Products & Services

Home » Membership » Join the OMA

Retired Physician and Physician Assistant Membership Application

by JenniferQuisenberry | August 15, 2012

We are looking forward to your membership with the OMA! Please fill out the secure application below.

CONTACT INFORMATION

Professional Designation: * required

MD

DO

PA

PA-C

Last Name : * required

First Name and Middle Initial: * required

Mailing Address: * required

CIty, Street, Zip: * required

Phone: * required

Applicant's Email Address: * required

How did you hear about the OMA? : * required

PROFESSIONAL INFORMATION

Are you currently licensed in Oregon?: * required

Yes

No

Medical School or PA Program: * required

Graduation Year: * required

Primary Specialty (If applicable):

Board Certified? :

Yes

No

N/A

Subspecialty (If applicable):

Board Certified? :

Yes

No

N/A

Subspecialty (If applicable):

Board Certified? :

Yes

No

N/A

PERSONAL INFORMATION

Birth date : * required

Birthplace : * required

Gender: * required

Male

Female

Spouse/Partner’s Name (For Alliance Use):

Spouse/Partner’s Email (For Alliance Use):

PROFESSIONAL AFFILIATIONS

Are you a member of the American Medical Association?: * required

Yes

No

N/A

Are you a member of a county medical society in Oregon?: * required

Yes

No

Have applied

If yes, which county medical society? :

AGREEMENT

I hereby apply for membership in the Oregon Medical Association and agree to abide by its bylaws and policies and the Principles of Medical Ethics of the Oregon Medical Association. If my medical license is issued by a state other than Oregon, I agree to notify the OMA of any changes to my licensure status. I authorize the OMA and its affiliates to communicate member benefit information by e-mail and facsimile.

Signature : * required

Date: * required

OTHER

If you have any questions, call OMA at (503) 619-8000 or send an e-mail to oma@theOMA.org.

I do not wish to receive member benefit information via e-mail. I understand that all newsletters and timely updates are sent via email and I will not be receiving these if I opt-out.

Printer-friendly version
Send to friend

Navigation

Join the OMA
Member Contact Information Update
Benefits of Membership
Members Only
Membership Sections
OMA Committees

Join OMA
Calendar of Events
Physician Finder
OMPAC Information
Member Forum

Directions
Site Map
Privacy Policy
Refund Policy

Join
OMPAC
OMEF
OMA Jobline
My Account