Physician-Led Hospital Membership
Contact Stacie Monroe at Stacie@physicianled.us or 419.250.5873 for questions.
Hospital Name
*
Contact Name
*
First Name
Last Name
Facility Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
List the names and e-mail addresses of any individuals who would like to receive e-mail updates.
Physician-Led Hospital Membership:
I Will Pay Hospital Membership Dues Based on Case Volume (See Calculation Below)
Hospital in First Year of Business (Opened in 2021) - $4,000
Hospital Under Construction - $2,500
Case Volume Calculation for Hospital Dues in your designated calendar year: Case Volume in 2022 (Inpatient, outpatient and pain procedures) multiplied by $2.00. (Minimum = $4,000; Maximum = $20,000.)
Submit
Should be Empty: