TIPAAA "Associate Membership" Application
  • Please review the following descriptions of TIPAAA Associate Membership classifications to determine which membership classification best suits your organization.  Current active TIPAAA Associate Members are comprised of companies & organizations that are either of the following:
    Vendor Organizations: Organizations which provide products and services directly to IPAs.  Examples of these are accounting, consulting, data processing and insurance organizations, or:
    Health Care Management Organizations:  Organizations which manage or provide practice management and related support services directly to IPAs.  These can include MSOs and PHOs.  If you have questions, please call 510-967-7305.
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  • SECTION 1 - Organization Information and Membership Levels
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  • How did you learn about TIPAAA?:*(If a specific person referred you, please provide his/her name, organization, state and member number).
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  • If there are any TIPAAA Associate Members from your organization, please list:*1.
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  • *2.
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  • *3.
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  • Select your desired level of Association below: For more information, please refer to the Associate Levels and Benefits matrix.
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  • Available levels of Associate Membership:*Individual Associate $285/AnnuallyCorporate Associate $5,000/AnnuallyKey Market Associate $25,000/Annually
    Desired Associate Membership Level
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  • Key Market, Key Corporate and Corporate Associate member additional employees ($200 Annually). For individual joining from existing Corporate, Key Corporate and Key Market Associates organizations – Complete Sections I, II, IV, V.
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  • SECTION II – Individual or Primary Corporate Associate Representative
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  • First Name:*
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  • Last Name:*
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  • Title:*
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  • Complete Company / Organization Name:*
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  • Organization Address:*
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  • City:*
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  • State:*
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  • Zip Code:*
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  • Phone:*
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  • Fax:*
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  • Email*
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  • Website Address:*
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  • SECTION III – Second Corporate Associate Representative
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  • First Name:*
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  • Last Name:*
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  • Title:*
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  • Complete Company / Organization Name:*
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  • Organization Adress:*
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  • Phone:*
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  • Fax:*
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  • Email:*
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  • Website Address:*
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  • SECTION IV – Organization Type
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  • *
    Accounting
    Consulting
    Data Processing
    Legal
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  • *
    Financial Services
    Health-related Association
    Insurance
    Employment/Recruitment Services
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  • *
    Medical Equipment
    Office Systems/Supply
    Pharmaceutical
    Other
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  • BENEFITS TO ASSOCIATES
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  • Interested?
    Please finalize this complete form and contact us if you or your company is interested in becoming a Partner or Sponsor of TIPAAA. Partner with TIPAAA today and put your message in front of the industry’s decision makers tomorrow!
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  • SECTION V – Payment Information
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  • Associate dues must be paid in full for your application to be processed. Please indicate payment method:
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  • *
    Credit Card (Please complete the following information.)
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  • Card Type:
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  • *
    VISA
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  • *
    MASTER CARD
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    AMERICAN EXPRESS
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  • Credit Card#:*
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  • Expiration Date:*
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  • CCV#:*
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  • Billing First Name:*As Shown on Card
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  • Last Name*As Shown on card:
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  • City:*
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  • State:*
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  • Zip Code:*
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    Check Payment (Payable to "TIPAAA")
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  • CHECK PAYMENTS Please fill in the following information:
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  • Total Reigstation Fee From Section (I):*
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  • Check#:*
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  • TIPAAA "Associate Membership"Application Submission
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  • Please complete all pages of this application form and it and a TIPAAA Representative will Contact you to Finalize your New Membership Registration Process: Contact Information: Please contact us in the manner below that is most convenient for you – we would love to hear from you!
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  • TIPAAA is a non profit {501 (c) 6} professional trade association. Your dues directly support TIPAAA’s educational programs, membership communications, industry collaboration, and public advocacy initiatives. Thank you for strengthening the role and voice of physician organizations.
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  • Your Company/Organizations "Logo"**please submit (2) logo files in full color & black and white.Upload
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    • SecureCaptchacopy the leters below into the text field before submission
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    • ©Copyright 1994-2017 TIPAAA® The IPA Association of America | A Non-Profit Organization, All Rights Reserved.
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