TIPAAA - New Membership Application
  • SECTION 1 - Organization Information:
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  • Company / Organization Name:*
    1
  • Address:*
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  • Website 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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  • Date Formed:*
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  • Organization Type:
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  • IPA*
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  • MSO*
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  • PHO*
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  • Primary Care*
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  • Multi Specialty*
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  • Single Specialty*
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  • Newly Formed*
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  • Other*
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  • Corporate Structure
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  • Corporation*
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  • Partnership*to order
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  • Non-Profit*to order
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  • Other:*
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  • Services Offered:*
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  • SECTION 2 - Contact Information | Senior Executive/Administrative Officer (CEO)
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  • First Name:*
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  • Last Name:*
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  • Title:*
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  • Shipping Address:*
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  • City:*
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  • State:*
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  • Zip Code:*
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  • Business Phone#:*
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  • Fax:*
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  • Email:*
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  • Primary Contact (if different from CEO)
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  • First Name:*
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  • Last Name:*
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  • Title:*
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  • Shipping Address:*
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  • City:*
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  • State:*
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  • Zip:*
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  • Phone:*
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  • Fax:*
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  • Email:*
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  • SECTION 3 - Medical Director/Physician Leader
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  • First Name:*
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  • Last Name:*
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  • Title:*
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  • Shipping Address:*
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  • City:*
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  • State:*
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  • Zip Code:*
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  • Business Phone:*
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  • Fax:*
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  • Email:*
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  • SECTION 4 - Organization Demographics
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  • Risk*
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  • Non-Risk*
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  • Other*
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  • Number of Managed Care Contracts*
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  • # Total Number of Managerd Care Covered Lives*Please be as accurate as possible
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  • # Physicians/M.D.s*Please be as accurate as possible
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  • # Number of Commercial Enrollees*Please be as accurate as possible
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  • # PCP's*Please be as accurate as possible
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  • # Number of Medicare Enrollees*Please be as accurate as possible
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  • # Specialists*Please be as accurate as possible
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  • # Number of Medicaid Enrollees*Please be as accurate as possible
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  • # PA's/RNP's*Please be as accurate as possible
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  • # Direct Contract/Self Pay Enrollees*Please be as accurate as possible
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  • # Support Staff*Please be as accurate as possible
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  • List your Company/Organizations three largest health plan and/or payer contracts (in order of size) below:
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  • List your primary hospital affiliates:
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  • 1.*
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  • 1.*
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  • 2.*
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  • 2.*
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  • 3.*
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  • 3.*
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  • SECTION 5 - Management Company Contacts | Management Company Information (if applicable)
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  • Name of Management Company:*
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  • Key Company Contact (If Different):*full name
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  • Name of Management Company CEO:*full name
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  • 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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  • Corporate Structure
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  • Corporation*
    95
  • Partnership*
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  • Non-Profit*
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  • Other*
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  • Number of Groups Managed/Owned*
    99
  • Date Formed*
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  • Services Offered*
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  • Management Company Information (if applicable)*(Will this management company be responsible for your annual dues renewal?
    YES
    NO
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  • IPA*
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  • MSO*
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  • PHO*
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  • Primary Care*
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  • Multi-Specialty*
    107
  • Single Specialty*
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  • Other*
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  • Client Organization Information | (Please complete for each group managed/owned.)
    110
  • Organization*
    111
  • Administrator/Primary Contact*
    112
  • Title*
    113
  • Address*
    114
  • State*
    115
  • Zip Code*
    116
  • Phone*
    117
  • Fax*
    118
  • Email*
    119
  • Organization Type
    120
  • IPA*
    121
  • MSO*
    122
  • Primary Care*
    123
  • Multi-Specialty*
    124
  • PHO*
    125
  • Single-Specialty*
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  • Other:*
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  • Managed/Owned Since:*
    128
  • Services Provided to Client:*
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  • SECTION 6 - Yearly Membership Dues = $650.00
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  • CREDIT CARD PAYMENTS By clicking the "submit" button below you will be redirected to our secure online credit card processing gateway for final New Membership Registration payment.
    Or Submit your payment via phone with by calling 1.510.967.7305
    *Payment is required to completely process your New Membership registration/application
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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"*upload up to (2) Logo files hereUpload
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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.
      www.TIPAAA.com
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