Application for Membership

To apply for membership in the Utah Medical Association, you may either call the Association office (801-747-3500) and we will mail you an application, or you may use the form below.

Please Note: After we receive your application, we will calculate your dues amount and send you an invoice.  You must send in your dues before your membership will be processed.  Medical Students and Physicians in Residency or Fellowship should call the UMA membership office at (801) 747-3500 for special membership data requirements after completing this application.

Your email address:

County Society
Please select the county society you wish to join from the list below. (There is a scroll bar to the right--you may have to adjust your window size to see it)

All applicants for anything other than affiliate or associate membership must choose a county medical society or section to join. The county selected must correspond to the county of residence or the county where you will be practicing.
Box Elder County Medical Society Cache Valley Medical Society Carbon-Emery Counties Medical Society Central Utah Medical Society Davis County Medical Society Iron County Medical Society Salt Lake County Medical Society Salt Lake County Medical Student Section (Medical Students) Salt Lake County Physicians In Training Section (Residents/Fellows) Skyline Medical Society Southeastern Utah Medical Society Summit County Medical Society Tooele County Medical Society Uintah Basin Medical Society Utah County Medical Society Washington County Medical Society Weber County Medical Society No County Society (affiliate/associate memberships only)

Name
Family Name:

First Name:

Middle Name:

Birth
Date of Birth (Month, day, year):

Place of Birth:

Home Address
Street:

City/State/Zip:

Home Phone:

Business Affiliation
Name of Practice/Clinic or Business Entity:

Office Phone number:

Fax:

Business Address
Street:

City/State/Zip:

Preferred Address for mailings (UMA Bulletin, other communications): Business Home

Which address should we publish in the UMA Directory? (Printed and Online): Business Do_Not_Publish Home

Preferred Billing Address (for sending dues invoices): Business Home Other
        If "Other," please fill in billing street address
                                              and City/State/Zip
 

Cell Phone/Pager# (for emergency use only - will not be shared):

 

Degree

M.D.

D.O.

Medical Student

DDS

P.A.

Pharm.D.

Other (list in NOTES field below)

Gender

Male

Female

Specialty Designations
Primary Specialty:

Subspecialty:

Licensure
Utah License Number:

Date of Licensure:

Academic Training
Medical School of Graduation (institution and city/state):

Date of Graduation:

Internship Location (institution and city/state):

Dates of Internship (From -- To):

Residency Location (institution and city/state):

Dates of Residency (From -- To):

Residency Location (institution and city/state):

Dates of Residency (From -- To):

Fellowship Location (institution and city/state):

Dates of Fellowship (From -- To):

Current UTAH Hospital Affiliations (list active staff only)
Hospital 1:

Hospital 2:

Hospital 3:

Hospital 4:

Other Professional Society Memberships

Board Certifications & Dates

Miscellaneous
Second language spoken:
Spouse's Name:

Read Carefully
Have you ever been convicted of fraud or a felony?

No

Yes

Has any action, in any jurisdiction, ever been taken regarding your license to practice medicine or prescribe controlled substances? This includes actions involving revocation, suspension, limitation, probation, or any other imposed sanctions or conditions.

No

Yes

Have you ever been the subject of any disciplinary action by any medical society or hospital staff?

No

Yes

If you answered "Yes" to any of the three questions above, you must forward full information to the Utah Medical Association before your application can be processed. Call the membership office at (801) 747-3500 for further information if needed.

NOTES or SPECIAL INSTRUCTIONS (optional)

BY SUBMITTING THIS APPLICATION, YOU HEREBY:

1.) release, and hold harmless from any liability or loss, your county medical society and the Utah Medical Association, their officers, agents, employees, and members for acts performed in good faith and without malice in connection with evaluating your application and your 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 representatives, concerning your professional competence, ethical conduct, character and other qualifications for membership; and

2.) agree to abide by the AMA Principles of Medical Ethics, the Economic Code of Medical Ethics for Utah Physicians, and the Bylaws of the Utah Medical Association and your county society if your application for membership is accepted; and

3.) accept that conviction for fraud or a felony, any licensure actions, or any disciplinary action taken by a hospital staff or medical society, after appropriate notice and hearing, may result in censure, suspension, or expulsion from membership in the Utah Medical Association and county medical society. The federal government requires professional societies to report actions that adversely affect membership, including denial of membership, to the National Practitioner Data Bank; and

4.) consent to receive communications sent by or in behalf of the Utah Medical Association or your county medical society via regular mail, email, telephone or fax.

When finished, you can , or if you want to start over.