Membership Application

OMDA - The Ohio Society for Post-Acute and Long-Term Care Medicine

Membership Application

January 1, 2019 - December 31, 2019


Prefix
First Name:
Last Name:
Suffix:
Credentials:
Title:
Facility:
Email:
Phone
Alternate Phone
Mailing Address: Business Home
Organization
Address:
City:
State
Zip
I serve as a:
Physician MD/DO
Advanced Practice Nurse NP/CNS
Physicians Assistant
Nurse RN/LPN
Dietitian/RDN
Pharmacist
Social Worker
Therapist OTR/PT/SLP/COTA/PTA
Administrator ED/DON/ADON
Industry/Corporate Professional
Fellow
Resident
Intern
Student
Other
I am a Certified Medical Director (CMD):
Yes
No
I have served as a Medical Director for years.
How did you learn about OMDA?

Membership Dues

Physician
$100.00/1 year
$180.00/2 year
NP, PA, RDN, IDT, Practice Manager, Retired
$50.00/1 year
$90.00/2 year
Providers in Training
Free
 
Payments to OMDA are not deductible as charitable contribution for federal income tax purposes. However, they may be deductible under other provisions of the Internal Revenue Code.
PRIVACY: Contact information and personal information collected during application process will be shared only for OMDA purposes. Some membership information will be listed in the membership directory accessible only to members.
   - denotes required fields