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Info Requests
Member Application
Step 1:
Member Info
Step 2:
Additional Info
Step 3:
Primary Contact
Step 4:
Billing Contact
Step 5:
Membership Options
Step 1:
Member Info
Company Name
*
Please add your company name.
Phone
*
Please add your company phone number.
Website
Email
*
Please add a valid email.
Physical Address
Address line 1
*
Please add your address.
Address line 2
City
*
Please add your City.
State
*
Please add your MN.
Postal Code
*
Please add your Postal Code.
Country
*
Choose...
Afghanistan
Albania
Algeria
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belgium
Belize
Bermuda
Bolivarian Republic of Venezuela
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Cambodia
Cameroon
Canada
Caribbean
Chile
China
Colombia
Congo [DRC]
Costa Rica
Croatia
Czech Republic
Denmark
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Greenland
Guatemala
Haiti
Honduras
Hong Kong
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea
Kuwait
Kyrgyzstan
Lao PDR
Latin America
Latvia
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia (Former Yugoslav Republic of Macedonia)
Malaysia
Maldives
Mali
Malta
Mexico
Moldova
Mongolia
Montenegro
Morocco
Myanmar
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Principality of Monaco
Puerto Rico
Réunion
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro (Former)
Singapore
Slovakia
Slovenia
Somalia
South Africa
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Tajikistan
Thailand
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
U.A.E.
Ukraine
United Kingdom
United States
Uruguay
Uzbekistan
Vietnam
Yemen
Please add your country.
Mailing Address
Same as physical address
Address line 1
*
Please add your address.
Address line 2
City
*
Please add your City.
State
*
Please add your MN.
Postal Code
*
Please add your Postal Code.
Country
*
Choose...
Afghanistan
Albania
Algeria
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belgium
Belize
Bermuda
Bolivarian Republic of Venezuela
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Cambodia
Cameroon
Canada
Caribbean
Chile
China
Colombia
Congo [DRC]
Costa Rica
Croatia
Czech Republic
Denmark
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Greenland
Guatemala
Haiti
Honduras
Hong Kong
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea
Kuwait
Kyrgyzstan
Lao PDR
Latin America
Latvia
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia (Former Yugoslav Republic of Macedonia)
Malaysia
Maldives
Mali
Malta
Mexico
Moldova
Mongolia
Montenegro
Morocco
Myanmar
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Principality of Monaco
Puerto Rico
Réunion
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro (Former)
Singapore
Slovakia
Slovenia
Somalia
South Africa
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Tajikistan
Thailand
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
U.A.E.
Ukraine
United Kingdom
United States
Uruguay
Uzbekistan
Vietnam
Yemen
Please add your country.
Step 2:
Additional Info
Business Description
*
Please add your company description.
Business Keywords
(enter a space between words)
IPA
*
Choose...
Yes, I am interested in the IPA.
No I am not interested in the IPA.
Please give me more information on the IPA.
Looks good!
Clinic Type (RHC, FQHC, other)
*
Looks good!
If ''other'', please describe here
Oral Health
EHR System
*
Looks good!
Clearinghouse
*
Looks good!
Vision
Behavioral
Step 3:
Primary Contact
First Name
*
Please add your first name.
Last Name
*
Please add your last name.
Title
Phone
*
Please add your phone number.
Cell Phone
Fax
*
Please add your fax number.
Email
*
Please add a valid email.
Contact Preference
Email
Phone
Address
Same as Address in Step 1
Address line 1
*
Please add your address.
Address line 2
City
*
Please add your City.
State
*
Please add your State.
Postal Code
*
Please add your Postal Code.
Country
*
Choose...
Afghanistan
Albania
Algeria
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belgium
Belize
Bermuda
Bolivarian Republic of Venezuela
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Cambodia
Cameroon
Canada
Caribbean
Chile
China
Colombia
Congo [DRC]
Costa Rica
Croatia
Czech Republic
Denmark
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Greenland
Guatemala
Haiti
Honduras
Hong Kong
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea
Kuwait
Kyrgyzstan
Lao PDR
Latin America
Latvia
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia (Former Yugoslav Republic of Macedonia)
Malaysia
Maldives
Mali
Malta
Mexico
Moldova
Mongolia
Montenegro
Morocco
Myanmar
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Principality of Monaco
Puerto Rico
Réunion
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro (Former)
Singapore
Slovakia
Slovenia
Somalia
South Africa
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Tajikistan
Thailand
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
U.A.E.
Ukraine
United Kingdom
United States
Uruguay
Uzbekistan
Vietnam
Yemen
Please add your country.
Create Account
This Login is already in use
Login
*
Please add your login username.
Password
*
Please add your login password.
Step 4:
Billing Contact
Same as Primary Contact
First Name
Last Name
Title
Phone
Cell Phone
Fax
Email
Contact Preference
Email
Phone
Address
Same as Address in Step 1
Address line 1
Address line 2
City
State
Postal Code
Country
Choose...
Afghanistan
Albania
Algeria
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Belgium
Belize
Bermuda
Bolivarian Republic of Venezuela
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei Darussalam
Bulgaria
Cambodia
Cameroon
Canada
Caribbean
Chile
China
Colombia
Congo [DRC]
Costa Rica
Croatia
Czech Republic
Denmark
Dominican Republic
Ecuador
Egypt
El Salvador
Eritrea
Estonia
Ethiopia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Greenland
Guatemala
Haiti
Honduras
Hong Kong
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Korea
Kuwait
Kyrgyzstan
Lao PDR
Latin America
Latvia
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia (Former Yugoslav Republic of Macedonia)
Malaysia
Maldives
Mali
Malta
Mexico
Moldova
Mongolia
Montenegro
Morocco
Myanmar
Nepal
Netherlands
New Zealand
Nicaragua
Nigeria
Norway
Oman
Pakistan
Panama
Paraguay
Peru
Philippines
Poland
Portugal
Principality of Monaco
Puerto Rico
Réunion
Romania
Russia
Rwanda
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro (Former)
Singapore
Slovakia
Slovenia
Somalia
South Africa
Spain
Sri Lanka
Sweden
Switzerland
Taiwan
Tajikistan
Thailand
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
U.A.E.
Ukraine
United Kingdom
United States
Uruguay
Uzbekistan
Vietnam
Yemen
Create Account
This Login is already in use
Login
Password
Step 5:
Membership Package
Please select a Membership Package
FQHC/RHC Entity
$1,000.00
$2,000,001 or more in operating expenses
FQHC/RHC Entity
$750.00
$500,001 to $2,000,000 in operating expenses
FQHC/RHC Entity
$500.00
Less than $500,000 in operating expenses
Organizational Membership
$480.00
Over 50 Employees
Organizational Membership
$320.00
26 - 50 Employees
Organizational Membership
$200.00
0-25 Employees
Individual
$20.00
Payment Option
Bill Me
Please complete the Captcha
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