TMA Membership Transition Form
Are you retiring, leaving the state, or leaving the practice of medicine? Please fill out TMA's Membership Transition Form so that we can have the most up-to-date records regarding membership. Your participation and feedback is appreciated. Thank you for your time and investment as a member of the Tennessee Medical Association.
Name
*
First Name
Last Name
Personal E-mail
*
example@example.com
Cell Phone Number
*
-
Area Code
Phone Number
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide your NPI number.
Why are you ending your membership with the Tennessee Medical Association?
*
I am retiring
I am moving out of the state
I am leaving the practice of medicine
Other*
*If you responded with "other" on the above question, please provide a short reason why.
What date are you leaving the practice, leaving the state, retiring, or other?
*
-
Month
-
Day
Year
Date
Please provide any comments you would like to pass along regarding your experience with the Tennessee Medical Association.
Visit tnmed.org/retiring-physician-guide/ for resources about closing your practice.
Submit Form
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