IMA PA/NP Membership Application

IMA PA/NP Membership Application

Thank you for your interest in membership with the Idaho Medical Association and your local County Medical Society. Please complete the application below with your professional, practice, and contact information. This information will be used to process your membership, maintain accurate records, communicate important updates and opportunities, and provide access to member services and events. All information submitted will be handled in accordance with applicable privacy and confidentiality practices.
Full Name

First NameLast Name
Degree
Date of Birth

MonthDayYear
Date
Gender
Spouse Name (if applicable)
Is your spouse a physician?
Office Information
Name of Employed or Supervising Physician Member
Practice Office Name
Practice Office Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Applicant's Practice Office Email
example@example.com
Office Manager Name
Office Manager Email
example@example.com
Office Phone
Please enter a valid phone number.Format: (000) 000-0000.
Office Fax
Please enter a valid phone number.Format: (000) 000-0000.
Personal Contact Information
You consent to receive IMA and County Medical Society communications electronically. However, if you do not consent and would like to opt out, please email membership@idmed.org. An email address is required to access IMA online services, including dues payments, profile updates, and event or workshop registrations. Some county medical societies also require an email address for member services and communications.

We request personal contact information to keep you informed about events and opportunities that may interest you, particularly as office-managed mailings may not always reach you directly. Information provided in the “Personal Contact Information” section will not be shared with outside individuals or organizations. However, under limited circumstances, certain event sponsors may receive attendee registration information for appropriate event-related follow-up.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone (with area code)
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone (with area code)
Please enter a valid phone number.Format: (000) 000-0000.
Personal Email
example@example.com
Professional Background & Credentials
Medical License #
Issue Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
NPI #
Primary Specialty
Profile Photo

Optional: upload a .jpg or .png photo of yourself for your online profile.
Cancelof
IMA Membership Qualification
Signature
Date

MonthDayYear
Date
Which email do you prefer IMA and your County Medical Society sends communications to (including newsletters and event info)?
Should be Empty:

IMA PA/NP Membership Application

Office Information

Personal Contact Information

Professional Background & Credentials