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Retired Status Membership Application for HCMA

  • Membership Details

    *This information is required
  • Date Format: MM slash DD slash YYYY
  • Education Details

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  • (Each member is listed once, by primary specialty, in the HCMA Membership Directory)
  • By my signature, I agree to accept and be bound by the Articles of Incorporation and Bylaws of the HCMA, and the Principles of Medical Ethics of the AMA, together with all future amendments of such Articles of Incorporation, Bylaws, or Principles of Medical Ethics, which may be duly adopted by the respective organizations.

    I, hereby release, and hold harmless from any liability or loss, the HCMA, their officers, agents, employees, and members for acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and hereby release from any liability any and all individuals and organizations, who, in good faith and without malice, provide information to the above named organizations, or to their authorized representatives, concerning my professional competence, ethical conduct, character, and other qualifications for membership. I understand that any false or misleading statements made on my application may be grounds for denial of membership or probation or censure by, or suspension of expulsion from, the HCMA.

    I hereby certify that the foregoing is true and correct to the best of my knowledge. I understand and agree that if I knowingly make a false representation on this application or a representation that in the exercise of reasonable care I should have known to be false, the HCMA has the authority to reject this application.

  • Date Format: MM slash DD slash YYYY
  • Billing Details

    *This information is required
  • Price: $100.00


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