Apply for Membership to The Medical Society of the County of Queens

Membership Application

Learn about the benefits of becoming a member of The Medical Society of the County of Queens.

To pay dues by credit card, follow this link
To pay dues by check, fill out the form below.

Apply For Membership by Check - Fill out this form
Step 1 :: Tell us about yourself
First name*
Last name*
Practice Name
Degree MD/DO
Date of Birth*	( please use format MM/DD/YYYY)*
Gender*
Primary Specialty*
Secondary Specialty
License#
Board Certifications
Board Certification Dates
NPI#
Foreign Languages spoken by Staff
Foreign Languages spoken by Doctor
Hospital Affiliation
Worker's Comp Rating
Office Manager's Name
Office Manager's Email
Step 2 :: Member sign in :: this will be your login to the members area
Email*
Password*
Step 3 :: Contact details
Phone*	( ) -
Home Phone	( ) -
Mobile	( ) -
Fax	( ) -
Which number would you like displayed in the printed directory?	Business Number Home Number
Business Address
Address 1*
Address 2
City*
State*
Zip*
Home Address
Address 1*
Address 2
City*
State*
Zip*
How would you like to be contacted?
By Phone	Business Number Home Number
By Mail	Business Address Home Address
Website	* PLEASE NOTE - USE THIS FORMAT * http://www.webeval.com
Step 4 :: Click the button below to submit your application
Comments
Notes

County and State membership are unified. Physicians may join the county society where they practice or reside.

Medical Society of the State of New York
Medical Society of the County of Queens

Established Physicians:$720 first year, $710 thereafter
1st - 2nd Year Practice: $480
Part-time (fewer than 20 hrs/week): $480
Resident / Fellow: $45

In addition, if you are not already an AMA member, we urge you to support the association that addresses national issues such as Medicare and Tort Reform. AMA Dues:

Regular: $420
2nd Year Practice: $315
1st Year Practice: $210

Please note: payment by check or online will follow on the next page, after your application is submitted.

Membership Application

Apply For Membership by Check - Fill out this form