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Member Connect® Registration Form

1. Information for Verification Purposes

First Name:
Last Name:
Middle Initial:
Date of Birth (mm/dd/yy):
Place of Birth - City:	State:

Country of Birth (if not United States):

2. Which of the following topics would you be interested in providing input to the American Medical Association on?

Payment Timeliness
Regulatory Relief
Managed Care Accountability
Expanding Health Insurance Coverage and Patient Choice
Medicare Payment Issues
Long-term Medicare Reform
Anti-trust Relief
Bioterrorism
Professional Medical Liability Reform
Patient Safety
Maintaining the Privacy of Confidential Medical Information
Public Health (Tobacco Control and Use Prevention, Alcohol and Other Drug Abuse, Violence Prevention)

3. Please provide your e-mail address so we can begin sending you Member Connect® surveys.

E-mail Address

4. Please provide your telephone number. We will only contact you by telephone if we encounter a problem with your registration form.

Telephone Number

Thank you for registering to participate in Member Connect®. Shortly, you will receive a survey to complete.

Press "Submit Survey" once now to send your responses to us.