MidAtlantic BONES New Member Application

MidAtlantic BONES New Member Application: Step 1

Please Note: You will need to allow pop-ups and redirects to use this form.
Name*

First NameLast NameSuffix
Title/Position*
Practice Name*
Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Website*
Member Email*
example@example.com
Practice Phone Number*

Area CodePhone Number
Mobile Phone Number (This is an optional field. By providing your mobile number you are opting into receiving text messages from MidAtlantic BONES. This information will not be shared or made public. You may opt out at any time.)

Area CodePhone Number
Ancillaries:*

Surgery CenterMRIPTDMEOther
Number of Doctors: *
Number of FTE Staff: *
Number of Locations:*
MidAtlantic BONES Membership Types

Active Member: ($60) Hold management position within the group which gives them the authority to hire and discharge personnel and be involved in the day to day management of the practice, and/or report directly to your physician.

Affiliate Member: ($45) Reports directly to the practice administrator and holds an assistant manager or supervisory position within the practice. Assists in the day to day operations of the practice in association with the practice administrator and in the absence of the practice administrator.
Membership Type:*

Active Member: $60Affiliate Member: $45
Please note your application is not complete until you submit payment.

Click the button below and you will be directed to a payment page to enter your credit card information.
Should be Empty:

MidAtlantic BONES New Member Application: Step 1