AGREEMENT FOR MEMBERSHIP IN THE NYSTPBA STATE TROOPERS SURGEONS GROUP
I hereby apply to become an affiliated Medical Professional and Associate Member of the New York State Troopers PBA State Troopers Surgeons Group. I acknowledge that the majority of PBA affiliated patients will present the Empire Plan (NYSHIP), which is predominantly the insurance that will be presented by active and retired members of the NYS Troopers PBA, their spouses and all eligible dependents. In the event that the Health Care Network that I am affiliated with is not a participating provider with the Empire Plan or other patient presented insurance group, I agree to ensure that any out of pocket expenses are fairly communicated with my patients. This agreement does not infringe upon my freedom of choice regarding patient selection, nor does it express or imply any constraints or limitations on my clinical judgment or course of treatment.
I understand that payment of State Trooper Surgeon Annual Dues provides a number of individual benefits to me. Any Corporate Relationship that the NYSTPBA has with an affiliated hospital or health care organization, with which I may be employed, will not impact my membership with the NYSTPBA, my individual relationship with my employer or the care that I will provide to my patients. I understand that the State Trooper Surgeons Group may publicize my Name, Contact Information, Hospital Affiliations and Medical Specialty to assist their members in locating my medical practice, should the need arise, and that the NYSTPBA or individual PBA Members do not require my membership as a Police Surgeon to obtain the medical care that I provide.
When physicians or medical professionals join the PBA as State Trooper Surgeons, Deputy Chief Surgeons, Chief Surgeons, Surgeon Affilitate Members, Medical Administrators or Chief Medical Administrators, they receive certain individual benefits. These benefits include: a Numbered State Trooper Surgeon Shield with ID and Wallet, a vehicle ID placard, PBA Stickers, PBA Cards, Access to PBA Sponsored CME Opportunities, Access to PBA Sponsored Group Rate Insurance Offerings and Access to the Surgeons Events and its Online Storefront.
In the event that membership with the State Trooper Surgeons Group is ended by the member or is terminated by the NYSTPBA for any reason, all affiliation claims must be eliminated from public view and end. The Board of Directors or its designee may investigate any complaints.
The Shield, ID card or placard will not be used to violate or abuse any municipal, vehicle & traffic, or penal laws. Should a member’s status as State Trooper Surgeon, the NYSTPBA Police Surgeon Shield, ID Card or Emergency Use Vehicle ID Placard be used in any way to imply any affiliation with, or impersonation of, the New York State Police or any law enforcement officer, the immediate revocation of membership and all affiliation with the NYSTPBA will result. All applicable laws are and will be in effect. I understand and accept that all applications are subject to a basic background check prior to membership approval.
In the event that I choose to terminate this membership, I agree to notify the PBA in writing at least thirty days in advance of the effective date of termination. I understand that the NYSTPBA reserves the right to terminate my membership in the NYSTPBA Surgeons Group. I understand that if my membership is discontinued for any reason; I will return all materials pertaining to the organization. I understand that failure to pay my yearly dues will result in the revocation of my membership and that I must return all PBA materials when requested to do so.
Please note that a $50 processing fee will be enforced for denied applications due to invalid or unsubmitted medical license, or for denied applications due to findings from our background check. The remainder of any paid dues at the time of application will be reimbursed to the applicant.
Checking the box below indicates my agreement to and acceptance of the terms and conditions of membership as outlined by the New York State Troopers PBA Board of Directors, and set forth in this application.