3 Ways to Join

  1. If paying by credit card (AmEx, MasterCard, or Visa), join online by completing the information below.
  2. Fax the printable membership form with credit card information to 410-740-4572.
  3. Mail the printable membership form with payment (check or credit card) to AMDA.

Please complete each section of the AMDA Online Membership Application in its entirety.  Review and select the appropriate membership category.
I. General Information
Were you ever a member of AMDA? 
If yes, during what time period?
Member ID:
Health Care Providers - Please provide your National Provider Identifier number:
 
Prefix First Name M.I. Last Name Suffix
* *
Credentials
Credentials 2
Credentials 3
Title:
Company:
Office Phone #: * Inc In Directory?
Fax #: Inc In Directory?
Email: * Inc In Directory?
Web Site: Inc In Directory?
Home Phone:
Cell Phone:
Preferred Method of Communication:
Primary Address: Home  Business 
Street Address: *
Apt.#
City/State/Zip: * *
Country:
Secondary Address: Home  Business 
Street Address:
Apt.#:
City/State/Zip:
Country:
How did you learn about AMDA?
Nursing Home Information:
Type the first few letters of your nursing home name to select from a list. If it is not listed, please send the nursing home name and address along with your name to membership@amda.com after completing your application. An AMDA staff member will have it added to your profile.
New: Medical Director at:
New: Attending Physician at:
II. Specialty
Primary Specialty:
Secondary Specialty:
Sub Specialty:
III. I serve as:
Check All That Apply
Medical Director   Attending Physician
Nurse Practitioner   Director of Nursing
Resident   Consultant Pharmacist
Adminstrator  
Other 
IV. Additional Information
Optional
Why did you Join AMDA?:
Check here if you would like information on your AMDA state chapter:
Would like to participate in AMDA's Mentorship Program? Yes, as a:
Tell us something about yourself:
V. AMDA offers the following membership categories*. Please select one.
NOTE: Only physician members hold voting rights.
Category: *
Amount:
VI. State Chapters.
Payment of state chapter dues is collected by AMDA for the following states:
 Colorado Medical Directors Association
 Illinois State Chapter
 Massachusetts State Chapter
 Maine State Chapter
 Michigan State Chapter
 Missouri State Chapter
 New Jersey State Chapter
 Ohio State Chapter
 Oklahoma State Chapter
 No Chapter
VII. AMDA Foundation.
AMDA supports the AMDA Foundation by contributing $1.00 from your dues to support the Foundation’s dual mission to educate, mentor and inspire current and future long term care professionals and to advance quality and improve care through long term care research. Additional donations to this autonomous 501(c)(3) corporation are welcomed (see below). Your donation is tax deductible. To learn more visit www.amdafoundation.org.
 Check here if you DO NOT want $1.00 to be contributed to the AMDA Foundation.
VIII. Summary.
Contribution to AMDA Foundation: $
AMDA Membership Dues: $
State Chapter Membership Dues: $
Total Due: $
* = Required Field

If you are a member of the American Medical Association (AMA), please designate AMDA as your specialty society when updating your AMA data.
Print Version     11000 Broken Land Parkway, Suite 400 Columbia, MD 21044
    Phone: 410-740-9743 • Toll free: 800-876-2632
    Fax: 410-740-4572 • E-mail: webmaster@amda.com