To become a MemorialCare Physician Society Member please complete the enrollment and agreement form below. *All fields are required. First Name * MI Last Name * Medical Specialty * Affiliations * Long Beach Memorial Miller Children’s Hospital Long Beach Community Hospital Long Beach Orange Coast Memorial Saddleback Memorial MemorialCare Medical Group Greater Newport Physicians Check all that apply Medical Staff Status * - Select -ActiveActive Community-AdmitActive Community-NonAdmitActive/AffiliateAffiliateAssociateConsultantCourtesyCourtesy InactiveEmergent/Urgent TCP'sFaculty Faculty/FellowFellowHonoraryHousestaffLocums TenensN/AProvisionalReciprocalSenior ActiveStudentTeaching ServiceTemporary Pending ApprovalTemporaryTemporary Provisional Practice Name * Practice Office Country United States Address 1 Address 2 City , State --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP Code Phone Fax * Enter none if you do not have a fax number Email Address * Shirt Size * - Select -Men’s SMen’s MMen’s LMen’s XLMen’s XXLWomen’s SWomen’s MWomen’s LWomen’s XLWomen’s XXL Membership Agreement MemorialCare extends its membership benefits and opportunities to physicians throughout our health system. Completion of this enrollment form and agreement to the following are required: I am a medical staff member in good standing at a MemorialCare Medical Center or affiliated medical group. I am committed to utilizing MemorialCare Best Practice guidelines when appropriate to my patient’s circumstances. I support and participate in physician performance reporting. I will become proficient in the MemorialCare clinical information system. I am committed to integrating evidence-based medicine into my practice. I will maintain an active email address for my Society communications. I understand that my membership in the MemorialCare Physician Society is contingent upon my fulfillment of these requirements and the approval of the Physician Society Board. Terms and Conditions I agree to the TERMS AND CONDITIONS. I certify that the information provided above is true and correct. I agree that MemorialCare, its representatives, and any individuals or entities providing information to MemorialCare in good faith shall not be liable to, to the fullest extent provided by law, for any act or occasion related to the evaluation or verification contained in this document. I hereby give permission to release information about my medical practice insurance coverage and malpractice claims history to MemorialCare. This authorization is expressly contingent upon my understanding that the information provided will be maintained in a confidential manner and will be shared only in the content of legitimate credentialing and peer review activities. This authorization is valid unless and until it is revoked by me in writing. I authorize the attorneys listed in this form to discuss any information regarding this case with MemorialCare. I agree * YES Note: Membership in MemorialCare Physician Society is at the sole discretion of MemorialCare. For additional information about the MemorialCare Physician Society or for questions about this form, please call 866-405-EPIC (3742). Verification * Type the characters you see in the picture; if you can't read them, submit the form and a new image will be generated. Not case sensitive. Switch to audio verification.